A CLINICAL OVERVIEW OF THE MAIN CHARACTERISTICS OF GORD, WITH AN EMPHASIS ON CHILDREN AND INFANTS
PART 1 BACKGROUND
Before I discuss gastro-oesophageal reflux disease (GORD) specifically in infants and children, in part 1 of this article I give a background on the condition, which includes information on GORD in adults. Part 2 of this article discusses GORD specific to younger children and infants. GORD is also called ‘gastric reflux disease’ or ‘acid reflux’. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms, such as heartburn, or complications such as oesophageal ulcers.
CAUSES
The oesophagus is a tube of muscle connecting the mouth to the stomach. In normal circumstances, the lower oesophageal sphincter (LOS) (the muscular ring at the lower end of the oesophagus) opens like a valve, enabling food to pass into the stomach, and then closes to prevent stomach acids seeping back into the oesophagus. However, in GORD, the sphincter pressure reduces, relaxing the muscle and allowing the stomach’s acidic contents to reflux into the oesophagus. The regurgitated stomach contents usually contain gastric acid and pepsin that are produced by the stomach (pepsin is an enzyme that helps digest proteins in the stomach). On occasions, bile that has backed-up into the stomach from the duodenum (the first part of the small intestine that attaches to the stomach) may also be present. Whilst pepsin and bile both irritate the lining of the oesophagus, the most damage and irritation is caused by gastric acid. What is commonly known as heartburn is in fact inflammation and a burning of the lining of the oesophagus due to repeated exposure to gastric acid. The severity of GORD can vary, depending on: How relaxed or damaged the oesophageal sphincter is. The type, amount and mix of fluid contents brought up from the stomach. The neutralising effects of saliva. A related condition called gastroparesis is caused by damage to those nerves within the intestinal tract that create peristalsis (the wave motion that moves and digests food). With this condition, the stomach takes longer to dispose of stomach acid, causing excess acids to build up and then release back through the LOS, resulting in gastric reflux. Gastroparesis is common in diabetics, as high blood sugar levels also damage nerves that control the function of the stomach.
Around 30 per cent of people with GORD have problems swallowing
SYMPTOMS
Symptoms described below relate to GORD experienced in older children and adults. Later, I will discuss symptoms more associated with younger children and infants. Heartburn This is the main symptom. It presents as a burning feeling of discomfort, rising from the upper abdomen or lower chest, up towards the neck. It has nothing to do with the heart. Regurgitation Regurgitation of acid up the oesophagus, often as far as the throat. This usually causes an unpleasant, sour taste. Dysphagia Dysphagia means difficulty swallowing. Around 30 per cent of people with GORD have problems swallowing. It occurs when scarring through repeated exposure to stomach acid causes the oesophagus to narrow, making food difficult to swallow. Many describe it as feeling like a piece of food becoming stuck somewhere near the breastbone.
Severe chest pain
This is a non-cardiac chest pain caused by GORD; this has been found in up to 50 per cent of patients with chest pain and normal coronary angiography. Usually, there is no relationship to exercise and this helps to differentiate most cases of refluxinduced chest pain from true angina. Other common symptoms include nausea, bloating and belching. These symptoms are periodic in nature and may flareup after eating, bending over, or after a period of lying down. Other symptoms caused by irritation and damage due to gastric acid exposure include: Experiencing pain or discomfort or difficulty when swallowing. A variety of dental problems, including enamel erosion and decay (due to gastric acid). Respiratory symptoms include laryngitis (causing pain, hoarseness), chronic cough, particularly at night (one-in-10 cases of chronic cough are caused by GORD) and asthmatic symptoms like wheezing and shortness of breath, probably due to irritation in the windpipe by reflux acid.
DIAGNOSIS
A doctor can often diagnose GORD from the symptoms the patient describes. Further tests may be advised if symptoms are severe, or do not improve with treatment, or are not typical of GORD. Tests will identify other possible causes of symptoms, such as bleeding from an ulcer, any abnormal growths, and for cancer of the oesophagus. Endoscopy An endoscope is a thin, flexible, fibreoptic tube with a video camera at one end commonly used to help identify the causes of abdominal pain, nausea and vomiting, heartburn, bleeding and swallowing disorders and to help diagnose gastrointestinal conditions. With oesophageal cases, this tool checks the surface of the oesophagus for damage by stomach acid. To maximise the effectiveness of the endoscopy, a period of fasting is required before the procedure can be performed. Endoscopy is advised if the person is over 55, or with unexplained, persistent symptoms or have presented with any of the alarm features outlined below indicating an increased risk of ulcers or cancer. Alarm features include:
- Unexplained loss of weight.
- Poor and/or painful swallow.
- Recurrent vomiting (perhaps containing blood).
- Blood in stools.
- Anaemia from gastrointestinal haemorrhage or upper abdominal mass.
- Any family history of colorectal cancer.
- Chronic NSAID use.
Like most cancers, early diagnosis and action maximise the likelihood of successful treatment. A specific style of treatment for this type of cancer is photodynamic therapy (PDT). This procedure involves injecting the oesophagus with a type of photosensitive medication, making it ultra-sensitive to light. Once done, a laser is then attached to an endoscope, which burns any cancerous cells.
Oesophageal manometry
If the outcome of an endoscopy is inconclusive, a further procedure called a manometry may be done. This test indicates how well the oesophagus moves food down to the stomach (peristalsis). Manometry can confirm GORD diagnosis or, if not, then perhaps a less common oesophageal problem such as muscle spasms or achalasia (a rare swallowing problem).
24-hour pH monitoring
If the manometry test cannot find any problems with the oesophageal sphincter muscles, another test called 24-hour pH monitoring can be used. It tests for acidity in the oesophageal area.
Barium swallow test
If the patient is showing dysphagia (poor swallow), they may be referred for a barium swallow test to fully assess their swallowing ability and identify difficulties such as blockages or muscle problems. To begin, the patient drinks a barium solution. The progress of the barium, once in the system, can then be tracked via x-ray.
HOW COMMON IS GORD IN THE GENERAL POPULATION?
The most common cause of indigestion in Ireland, GORD affects up to one-in-four people. Some 10-to-20 per cent of people in the Western world have at least one bout of GORD per week. This figure is only about 5 per cent in Asia, which gives an indication that our Western diet, which tends to have a higher fat content, is a factor in GORD. GORD can affect people at any age, including infants and young children. A typical sufferer is twice as likely to be male as female. It is also a common problem for babies and infants, leading to difficulty feeding in more severe cases. It can be controlled by food thickeners, alginates and removing cow’s milk from the infant’s diet if caused by lactose intolerance.
PART 2: GORD IN INFANTS AND CHILDREN HOW COMMON IS GORD IN INFANTS?
The most obvious symptoms of reflux in infants is vomiting or regurgitation. All healthy infants have a tendency for GORD and it is natural for an infant to have a certain amount of regurgitation after feeding. The issue is whether GORD is causing a problem in an infant, rather than whether GORD is occurring at all. Reflux is most common between one-tofour months and approximately 67 per cent of infants have more than one daily episode of regurgitation at four months. Between the ages of six-to-seven months, symptoms of reflux decrease from 61 per cent down to 21 per cent. At 12 months of age, only 5 per cent have symptoms. By 12-to-18 months, most cases of GORD will resolve as the sphincter (valve between oesophagus and stomach) matures, the infant adopts an upright posture and begins having a more solid diet.
SYMPTOMS OF REFLUX IN INFANTS
I discussed symptoms earlier in adults and older children. This time, I discuss symptoms more common in younger children and infants. Reflux causes frequent or recurring vomiting. This is not the small mouthfuls of vomit seen in all infants, but the vomiting of large amounts. This can happen straight after a feed, or right up until the next feed. When the infant’s oesophagus becomes sore from exposure to the regurgitated acid (the equivalent of heartburn), this leads to irritability, pain and poor feeding. If GORD is severe, the infant may have difficulty gaining weight. Other common symptoms of reflux include; Sometimes screaming suddenly when asleep. Infants can be inconsolable, especially when laid down flat. Poor sleep habits, typically with arching their necks and back during or after feeding. Frequent burping or frequent hiccups. Swallowing problems. Frequent ear infect ions or sinus congestion. Infants are often very windy and extremely difficult to burp after feeds; failure to wind them successfully usually means ref lux and vomiting are worsening. Refusing feeds or frequent feeds for comfort. Night-time coughing. Sometimes reflux can happen so quickly that it leads to the infant inhaling vomit, leading to respiratory problems such as asthma, bronchitis and even chest infections.
WHEN TO REFER?
It is very rare for reflux to lead to serious complications. But some infants do have problems and the parent should see a GP if the infant vomits severely or has any of the following symptoms: Blood or bile (bile is a yellow fluid) in their vomit. Difficulty in swallowing or is choking easily. A fever. Is irritable, crying and hard to settle. Listlessness, dark circles under the eyes, refusal to feed, and dry nappies. Breathing problems that could lead to apnoea (the infant may temporarily stop breathing). Is losing weight or not gaining weight as per normal.
TREATMENT
Avoid overfeeding and try increasing frequency and decreasing volume of feeds. The infant should be supported in an upright position whilst feeding and for at least 45 minutes after feeding to bring up wind. The infant should be handled very gently after feeding and during winding; avoid vigorous patting or rocking. GORD tends to be worse when lying flat and therefore a gentle raise of the head of an infant’s cot can be useful, so that the infant’s head is higher than the rest of their body while they sleep. This can be done by putting a pillow or folded blanket under the mattress to create a gentle up-slope. Never attempt to let the infant sleep directly on a pillow, which could be dangerous.
PRODUCTS TO ADD TO AN INFANT’S FOOD
By thickening their food, an infant is less likely to bring it back up. There are products to thicken an infant’s milk, for example, Instant Carobel. There are also ready-thickened feeds such as SMA Staydown. If breastfeeding and the infant is having problems with bringing up food, Gaviscon Infant sachets may be used instead of the above mentioned products. Infants are less likely to bring up food if they have sodium alginate (Gaviscon Infant) mixed with their feed or dissolved in water after their meal. Sodium alginate works in three ways: It thickens the milk, making it easier for the infant to cope with; coats the oesophagus all the way down to the stomach; and in the stomach, it forms a raft over the stomach contents, helping to stop the contents of the stomach from escaping back up the oesophagus. Dosage depends on the weight of the infant. Gaviscon Infant sachet(s) can be mixed with cool boiled water, milk feed or expressed breast milk. Gaviscon Infant sachet(s) should not be administered more than six times in 24 hours. Gaviscon Infant should not be given to premature infants, young children who are ill with a high temperature, diarrhoea, vomiting, or if already using a food thickener.
A proton pump inhibitor reduces the acidity of the stomach’s contents and is more potent than H2 antagonists
MEDICATION
Anti-reflux medicines reduce the severity of the reflux by improving the downward movement (ie, motility) of the oesophagus and stomach. They may also reduce acidity so that the reflux is less damaging to the oesophageal lining. They are generally only used if other treatment options like thickeners do not work. Domperidone helps tighten the valve (called the sphincter) at the end of the oesophagus where it joins the stomach. This will help stop food from flowing back into the oesophagus. It comes in liquid or rectal (suppository form) form for infants and children, but is only available with a doctor’s prescription. Directions: By mouth — over one month and body weight up to 35kg, 250-500mcg/kg three to four times a day; body weight 35kg and over, 10-20mg three-to-four times daily, max 80mg daily.
By rectum — body weight over 15kg, one 30mg Motilium Suppository twice a day, body weight over 35kg, 60mg twice daily. Some young children taking domperidone may get mild diarrhoea. H2 blockers reduce the amount of acid in the stomach. Ranitidine, a type of H2 antagonist, was often used for GORD in infants until it was recalled in 2019. Omeprazole Liquid (available as an unlicensed medication in Ireland) and Losec MUPS (omeprazole) are the most used proton pump inhibitors for children. Losec MUPS can be dissolved in water, which is convenient for children’s dosage.
A proton pump inhibitor reduces the acidity of the stomach’s contents and is more potent than H2 antagonists. The dose for infants and young children is based on body weight and the doctor will decide the correct dose. Directions: Newborn infant under four weeks, 700mcg/kg once daily, increased if necessary after 7-14 days to 1.4mg/kg once daily. Child one month to two years, 700mcg/kg once daily, increased if necessary to 3mg/kg, max 20mg once daily. Dosage range for omeprazole by weight: Child’s body weight 10-20kg: 10mg once daily (max 20mg/day). Galmiche JP, Janssens J; The Pathophysiology of Gastro-oesophageal Reflux Disease: An Overview. Scandinavian Journal of Gastroenterology. 1995, Vol 30, No s211, Pages 7-18. PJ Kahrilas. Gastro-oesophageal Reflux Disease. New England Journal of Medicine, 2008. All PPIs are equivalent for treatment of GORD (POEM). The Pharmaceutical Journal. Vol 275 No 7380 p736.
Dec 2005. Nickless G, Morgan P. Gastro-oesophageal reflux disease and its management. The Pharmaceutical Journal, 1 Dec 2009. Patient information from the BMJ Group. GORD in young children. March 21, 2012. Stringer D MS FRCS FRCP. Gastro-oesophageal reflux. TOF young children by TOFS (Tracheo- Oesophageal Fistula Support). Clinical practice guidelines. The Royal Young Children’s Hospital Melbourne, GORD in young children, May 2012. Liburd J, Hebra A; GORD. eMedicine, May 2009; Paediatric Article. BIBLIOGRAPHY Child’s body weight over 20kg: 20mg once daily (max 40mg/day).
SURGERY
Surgery is required in a minority of infants with severe GORD who do not respond to treatment; surgery is not always successful. Sometimes medication needs to be continued after surgery. ? Disclaimer: Brands mentioned in this article are meant as examples only and not meant as preference to other brands.
BIBLIOGRAPHY
Galmiche JP, Janssens J; The Pathophysiology of Gastro-oesophageal Reflux Disease: An Overview. Scandinavian Journal of Gastroenterology. 1995, Vol 30, No s211, Pages 7-18. PJ Kahrilas. Gastro-oesophageal Reflux Disease. New England Journal of Medicine, 2008. All PPIs are equivalent for treatment of GORD (POEM). The Pharmaceutical Journal. Vol 275 No 7380 p736. Dec 2005. Nickless G, Morgan P. Gastro-oesophageal reflux disease and its management. The Pharmaceutical Journal, 1 Dec 2009. Patient information from the BMJ Group. GORD in young children. March 21, 2012. Stringer D MS FRCS FRCP. Gastro-oesophageal reflux. TOF young children by TOFS (Tracheo- Oesophageal Fistula Support). Clinical practice guidelines. The Royal Young Children’s Hospital Melbourne, GORD in young children, May 2012. Liburd J, Hebra A; GORD. eMedicine, May 2009; Paediatric Article.
CONTRIBUTOR INFORMATION
Written and researched by Eamonn Brady (MPSI), owner of Whelehans Pharmacies in Mullingar Tel 04493 34591 (Pearse St) or 04493 10266 (Clonmore). www. whelehans.inet. Eamonn specialises in the supply of medicines and training needs of nursing homes throughout Ireland. Email ebrady@whelehans.ie
