Gastro-oesophageal Reflux

Summary
Introduction
When might GOR be pathological?
Differential Diagnosis (of vomiting)
Diagnosis of GOR
Management
Areas of Uncertainty in Clinical Practice

Summary

some GOR occurs in most premature infants, but it is usually not pathological
a 24-hour pH probe study is the gold standard for the diagnosis of occult GOR, but requires the gastric contents to be acidic
non-pharmacological measures should be adopted first in the treatment of GOR
pharmacological treatment of GOR should only be undertaken where there is proven, pathological reflux

Introduction

Gastro-oesophageal reflux (GOR) may be defined as the spontaneous effortless regurgitation of gastric contents into the oesophagus. This may or may not result in vomiting. Although some (physiological) reflux occurs in most premature infants, the total amount of reflux in a 24-hour period is usually not grossly abnormal. Preterm infants appear to have fewer and shorter episodes of reflux than term infants. Therefore, the investigation and management of GOR in the neonatal nursery should be reserved for those infants in whom the reflux is considered to be pathological.

When might GOR be pathological?

delayed acid clearance resulting in
- bleeding
- stricture (incidence unknown)

pulmonary complications
- apnoea (however, most apnoea is not due to GOR)
- aspiration
- exacerbation of chronic lung disease in some cases

failure to thrive, secondary to poor intake

apparent life-threatening events and SIDS (controversial)

Differential Diagnosis (of vomiting)

drugs e.g. theophylline and caffeine
inborn errors of metabolism
pyloric stenosis (GOR usually not projectile)
bowel obstruction (usually bile-stained vomiting)
sepsis (especially UTI)
necrotising enterocolitis

Diagnosis of GOR

usually clinical
barium swallow and ultrasound nonspecific (only useful to rule out structural abnormalities)
24-hour pH probe gold standard, although gastric contents must be acid
demonstration of acid in oral secretions by using litmus paper (wont diagnose reflux into lower oesophagus)
white oral secretions may be differentiated from milk if milk is tinged with methylene blue (few drops only)
endoscopy little data available for preterm infants
radio-nucleotide studies not standardised in preterm infants
oesophageal manometry catheter size limits usefulness in VLBW

Management

Non-pharmacological
- prone +/- 30-degree elevation (beware increased risk of SIDS if prone - apnoea monitoring required), alternatively left side down
- increased frequency (thus decreased volume) of feeds
- indwelling vs. intermittent tube insertion
- continuous feeding (gastric or transpyloric)
- thickeners including Karicare, Carobel, Gaviscon
- fundoplication (reserved where intractable or life-threatening proven GOR and failed pharmacological therapy)

Pharmacological only for proven, pathological GOR
- Antacid therapies e.g. Gaviscon, Mylanta
- H2 blockers e.g. Ranitidine
- Proton pump inhibitors e.g. Omeprazole (expensive)

Areas of Uncertainty in Clinical Practice

the role of GOR in the aetiology of SIDS
reflux-specific behavioural criteria (e.g. discomfort, head retraction and mouthing) may be inappropriate as diagnostic criteria for GOR in premature infants

References

Novak DA. Gastroesophageal reflux in the preterm infant. Clin Perinatol 1996;23:305-20

Vandenplas Y, et al. The role of cisapride in the treatment of pediatric gastroesophageal reflux. A medical position statement of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 1999;28:518-28

Gilbert RE, et al. Cisapride treatment for gastro-oesophageal reflux in children: A systematic review of randomized controlled trials. J Paediatr Child Health 2000;36:524-9