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 patient’s 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 obstruction8,9
    • 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

Billious vomit
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

Sunset Eyes
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 stenosis11,12
  • 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 pepsin13,14
      • Hence, frequent middle ear infections should raise the possibility of reflux2