Gastro-oesophageal reflux: Clinical assessment and risk stratification

GOR is likely when:

• There are no symptoms of serious illness (including sepsis).
• The child appears well with a normal examination.
• The vomiting is non-bilious and non-projectile.
• The child has plenty of wet and dirty nappies.
• The child is thriving.
• There are no features of gastro-oesophageal reflux disease (GORD):
  • This is GOR that causes symptoms severe enough to merit medical treatment or reflux-associated complications²

A note on thriving:

• It is normal for a neonate to lose weight within the first few weeks of life especially if breast-fed.
• A general rule of thumb is no more than 10% of the birth weight and should be regained by day fourteen.
• However, this is based upon factors that predispose to jaundice and is highly controversial⁵.
• Recent evidence would suggest over 25% of otherwise healthy breast-fed neonates exceed these limits⁶.
• After this initial period insufficient growth should be determined by comparing the patients birth weight to the current weight on a growth curve.

Symptoms suggestive of serious illness:

• Bilious vomiting:
  • 23-38% of neonates admitted with green vomitus were shown to have a surgical obstruction^8,9
  • It is important to ask about the colour of the vomit rather than use the term bilious, as most parents equated bile with the colour yellow⁷
• Projectile vomiting:
  • 66-84% of cases will have pyloric stenosis³
• Poor urine and/or stool output:
  • May indicate dehydration
• Excessive weight loss or pathological jaundice:
  • May indicate dehydration

Image: Billious vomit
Signs suggestive of serious illness:

• Abnormal vital signs (including fever >38 C)
• Failure to thrive
• Pathological jaundice (see previous module)
• Signs of raised intracranial pressure:
  • Bulging fontanelle, rapidly increasing head circumference and sunset eyes
  • Hence, head circumference should be considered part of the standard examination
• Signs of dehydration:
  • Sunken fontanelle, poor capillary refill and decreased skin turgor

Image: Sunset eyes – up-gaze paresis with the eyes appearing driven downward
Signs suggestive of serious illness:

• Distended abdomen:
  • 61.8% of full-term new-borns with abdominal distension have a congenital malformation (including congenital megacolon, anal atresia, malrotation, and intestinal atresia)¹⁰
• Hepatomegaly:
  • May indicate inborn errors of metabolism
• An olive-sized mass in the right upper quadrant:
  • Reported in 50% to 83% of cases of pyloric stenosis^11,12
• Groin lump:
  • May indicate an incarcerated inguinal hernia

Features suggestive of GORD:

• Marked distress:
  • Currently defined as outside the normal range by an appropriately trained healthcare professional
• However:
  • There is no persuasive evidence that prolonged crying or waking at night is related to GORD and there are other potential explanations²
  • There is some evidence that abnormal posturing may be more suggestive especially if there are features of Sandifer’s syndrome²
  • Episodic torticollis with neck extension and/or rotation that may be mistaken for seizure activity
• Apnoea:
  • Observation studies suggest apnoea and GOR are rarely associated unless overt regurgitation is associated with the episodes²
  • Hence, other causes of acute life threatening events should be excluded beforehand
• Feeding difficulties:
  • Feed refusal, gagging and choking
  • As with apnoea, observational studies suggest little evidence to support feeding difficulties are linked with GOR unless overt regurgitation is associated with the episodes²
• Faltering growth:
  • Observational studies are highly variable with regards to the association between failure to thrive and GORD²
  • However, overall consensus would suggest that faltering growth could be related to GORD however, other causes should be excluded first²
• Chronic cough/hoarseness of voice:
  • Observational studies suggest no association between GOR and laryngeal inflammation in children²
  • In the absence of associated overt regurgitation the presence of chronic cough or hoarse voice does not indicate the presence of GOR
• Complications:
  • Reflux oesophagitis
    • Upper GI bleeding, unexplained iron-deficiency anaemia, dysphagia
  • Recurrent aspiration pneumonia
    • Single episodes of pneumonia are relatively common in childhood however, consider if recurrent
  • Frequent otitis media:
    • Studies have demonstrated refluxate in the middle ear due to the presence of the digestive enzyme pepsin^13,14
    • Hence, frequent middle ear infections should raise the possibility of reflux²