Gastro oesophageal reflux (GOR) in neonates

Key messages

 Most infants with recurrent apnoea and bradycardia do not have gastro-oesophageal reflux.

 GOR is very common in preterm infants and rarely pathological

 Most infants with gastro-oesophageal reflux do not require pharmacological intervention.

 Investigation and management of GOR in the neonatal nursery should be reserved for those
infants in whom the reflux is considered to be pathological Gastro Oesophageal Reflux Disease
(GORD).

Gastro-oesophageal reflux (GOR) is the spontaneous effortless regurgitation of gastric contents into the
oesophagus that may or may not result in vomiting. It is a self limiting condition and often resolves by 18
months with or without treatment.

Physiological reflux occurs in most premature infants but the total amount of reflux in a 24-hour period
is usually not grossly abnormal. It is due to oesophageal sphincter relaxation, slower gastric motility and
increased gastric acidity. When it becomes more severe & is associated with other symptoms, it is
considered pathological (GORD). Investigation and management of GOR in the neonatal nursery should
be reserved for those infants in whom the reflux is considered to be pathological (GORD).

GOR issues to note

Issues to note about infants with Gastro-oesophageal reflux:

 Most infants having recurrent apnoeas and bradycardia do not have GORD.

 Some GOR occurs in most premature infants, but it is usually not pathological.

 There is no gold standard for the diagnosis of occult GOR, although research into multi-channel
intraluminal impedance is promising

 In general non-pharmacological measures should be adopted first in the treatment of GOR.

 Most infants do not require pharmacological intervention.

 Pharmacological treatment of GOR should only be undertaken where there is proven,

pathological reflux( GORD).

 Where pharmacological treatment is commenced it should be discontinued after a trial period

(eg two weeks) if it is ineffective.

When the lower oesophageal sphincterthe muscle that acts as a valve between the esophagus and
stomach has not fully developed in infants, GOR can occur. While the sphincter muscle is still
developing, it may push stomach contents back up, resulting in regurgitation.
Figure 1: Mechanism of GOR

Source: National Digestive Diseases Information Clearinghouse (NDDIC)

When might GOR be pathological (GORD)?

These features may indicate that GOR has become pathological:

 delayed acid clearance resulting in bleeding

 stricture (incidence unknown)

 pulmonary complications

 apnoea (however, most apnoea is not due to GORD)

 cyanotic episodes

 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)

Differential diagnosis of vomiting involves investigation for:

  drugs eg 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

Diagnosis for GOR is usually clinical and may involve:

 barium swallow and ultrasound nonspecific (only useful to rule out structural abnormalities)

 24-hour pH probe, although gastric contents must be acid preterm infants tend to be on
frequent sometimes continuous milk feeds which buffer gastric acid and this limits the use of
the pH probe in neonates

 demonstration of acid in oral secretions by using litmus paper (will not 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 is available for preterm infants

 radio-nucleotide studies not standardised in preterm infants

 oesophageal manometry catheter size limits usefulness in VLBW

Management of GOR

Non-pharmacological management

Non-pharmacological management of GOR involves:

 Prone or left lateral positioning has been shown to reduce symptoms of GOR as the gastro
oesophageal junction is clear of fluid in this position.In the Neonatal nursery, where infants are
monitored & continually observed, prone and left lateral positions may be implemented. It is
however recommended that continuous cardiorespiratory monitoring and oxygen saturation
monitoring be used in these circumstances (not just apnoea monitoring)

 As babies mature they should be placed on their back on a firm flat mattress that is not elevated
or tilted as soon as possible and prior to discharge
  Elevating the sleeping surface for back sleeping babies does not reduce GOR and is not
recommended.

 Increased frequency of feeds (decrease the volume).

 Indwelling vs. intermittent tube insertion

 Continuous feeding (gastric or transpyloric) although there is little evidence for this.

 Thickeners including Karicare, Carobel, Gaviscon , although there is no current research to

support or refute their effectiveness.

 Trial of extensively hydrolyzed or cow’s milk protein-free formula

Pharmacological management for proven, pathological GORD

The objective here is to reduce the acidity of stomach contents, not to treat the GOR itself. Treatment
options may involve:

 antacid therapies eg Gaviscon, Mylanta

 H2 blockers eg Ranitidine

 proton pump inhibitors eg Omeprazole

Discharge planning

Family education is paramount in emphasizing safe sleeping positioning for babies at discharge. SIDS and
Kids recommend that all babies, including those with GOR, sleep on their back on a firm, clean and well-
fitting mattress that is flat (not tilted or elevated) to reduce the risk of SUDI, including SIDS and fatal
sleeping accidents. Babies should not be discharged home to lie in the prone position unless they are
awake and being closely observed by an adult at all times.

Gastro Oesophageal Reflux Information Statement

Issues to note:

 Medications that reduce gastric acidity may alter GIT flora and increase the risk of NEC so should
be avoided in low birth weight infants. There is an increased risk of hospitalisation with lower
respiratory tract infection in infants treated with Omeprazole.

 Metoclopramide (Maxolon) is not recommended as it may cause irritability, apnoea and

dystonia.

 Fundoplication is rarely used and would only be indicated for intractable or life-threatening
proven GORD and failed pharmacological therapy.

Areas of uncertainty in clinical practice

  Reflux-specific behavioural criteria (eg discomfort, head retraction and mouthing) may be
inappropriate as diagnostic criteria for GOR in premature infants.

 The role of agents (eg domperidone, erythromycin) that enhance gastric emptying.

 A new GORD behavioural score is currently being developed but is yet to be validated.

More information

References

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

 Birch JL, Newell SJ. Gastrooesophageal reflux disease in preterm infants: current management
and diagnostic dilemmas. Arch Dis Child Fetal Neonatal Ed 2009;94:F379-83

 Poets C. Gastrooesophageal reflux: A critical review of its role in preterm infants. Pediatrics
2004;113:e128-32

 Newson, L., Childhood Gastro-oesophageal Reflux, 2012

Further reading

 Orenstein SR. Gastroesophageal reflux. Pediatrics in Review 1999;20:24-8

 Lander A. The risks and benefits of cisapride in premature neonates, infants, and children. Arch
Dis Child 1998;79:469-70

 Badriul H, Vandenplas Y. Gastro-oesophageal reflux in infancy. J Gastroenterol Hepatol

199;14:13-9

 Page M, Jeffery H. The role of gastro-oesophageal reflux in the aetiology of SIDS. Early Hum Dev
2000;59:127-49

 Newell SJ, Booth IW, Morgan MEI, et al. Gastro-oesophageal reflux in preterm infants. Arch Dis
Child 1989;64:780

 Czinn S, Blanchard S. Gastroesophageal Reflux Disease in Neonates and Infants When and How
to Treat Pediatr Drugs (2013) 15:1927