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Gastroesophageal reflux disease

What is gastroesophageal reflux disease or GORD?

Gastroesophageal reflux (GOR) is a common condition in infants and babies where the contents of the stomach moves up and into the feeding tube (oesophagus) and sometimes into the mouth. This is very common and is a normal process. If however the baby becomes symptomatic (eg experiencing pain or weight loss) then we call it Gastroesophageal reflux disease (GORD). Note that in America,because of the spelling of oesophagus, this becomes “GERD”.

The picture above shows the normal position of the feeding tube (oesophagus) and the stomach. The picture below shows how the valve at the bottom of the feeding tube fails in gastroesophageal reflux disease.

Signs & symptoms

Regurgitation appears to be commonest around 4 months of age with 60% of children having symptoms. This decreases to about 20% by 7 months of age and then nearly all children are symptom free by 1 year of age.

Gastroesophageal reflux (GOR) is different to gastroesophageal reflux disease (GORD). GOR is very common in babies and peaks at around 4 months of age. Refluxing without symptoms is normal.This is sometimes called “regurgitation”. It only becomes a problem (and hence is termed GORD) when it begins to impact on the health of a baby. This may be with evidence of pain after feeding, weight loss or other features.Remember to look out for the warning signs or “red flags” which are listed below.

Regurgitation occurs in about 50% of 0-3 month olds and gradually decreases to about 5% at 12 months of age. So you can see that time is a great healer.

Gastroesophageal reflux disease usually improves with the addition of thickeners, the introduction of a cows milk & soya free diet, or with the addition of anti-acid therapy. Note that if you are allergic to cows milk protein you have a roughly 1 in 2 chance of also being allergic to soya protein. 

Red flags

It is important to determine if there is an underlying problem that is causing the reflux.

Warning signs include

  • Bile stained vomiting
  • Vomiting blood
  • Black tar like poo
  • Onset of vomiting after 6 months
  • Constipation or diarrhoea
  • Abdominal pain
  • Recurrent chest infection
  • Large liver or spleen
  • Neurological symptoms (eg muscle weakness)
  • Rapidly increasing head circumference
  • Fever or irritability
  • Poor weight gain

Silent reflux

“Silent reflux” is a slightly confusing term which technically is described as “laryngeal-pharyngeal reflux”. This means that there is movement of stomach contents (that can be acidic) into the area around the throat and vocal cords. It is characterised by a hoarse voice, frequent throat clearing and coughing.

There is a suggested link between “silent reflux” and asthma as the movement of acid up the oesophagus can stimulate nerves that can then cause coughing and wheeze. Researchers are investigating the links between silent reflux and recurrent ear infections but this link has not as yet been proven.

Treatment

Treatment usually follows the following steps:

1.Ensure that there are no warning signs or red flags

2. If evidence of poor weight gain, distress with feeding, blood in stools or vomit, eczema or strong family history of allergic disease then consider a cow’s milk and soya free diet and review after 2-4 weeks to see if there has been any improvement.

3. If cow’s milk/soy allergy is not considered likely then add thickeners to formula milk or expressed breast milk.

Commonly used thickeners include “Carobel” and “Thick n’ easy”. (note that Gaviscon acts as a thickener in babies rather than as an anti-acid). Also stop any exposure to tobacco smoke because we know that tobacco smoke can worsen reflux.

4. If the addition of thickeners do not improve the symptoms then consider acid suppression using ranitidine or omeprazole for a 2 week period.

If this helps, then continue for 3 months. Because of the increased side effects with omeprazole we would recommend starting with ranitidine first.

5. If acid suppression treatment doesn’t work then blood tests should be carried out (including a screen for coeliac disease if exposure to wheat,rye or barley has occurred) and a referral for an endoscopy should be considered. 

Occassionally patients will need evaluation in hospital but surgery is very rare in children under 1 year of age. 

  • Ranitidine
  • Omeprazole
  • Formula milks
  • NICE guideline
  • Author & Review date

Ranitidine  (Also known as Ranitic®, Zantac®)

What is ranitidine?

Ranitidine is an anti-acid drug. It works by reducing the amount of acid in the stomach. In Gastroesophageal reflux disease, the acid coming back up the oesophagus can cause pain and discomfort. Ranitidine therefore helps to reduce this by reducing the amount of acid that is present.

When should I give ranitidine?

Ranitidine may be given once, twice or three times each day. Your doctor will tell you how often to give it.

Give the medicine at about the same time(s) each day so that this becomes part of your child’s daily routine.

How much should I give?

Your doctor will work out the amount of ranitidine (the dose) that is right for your child. The dose will be shown on the medicine label.

What if my child is sick (vomits)?

  • If your child is sick less than 30 minutes after having a dose of ranitidine, give them the same dose again.
  • If your child is sick more than 30 minutes after having a dose of ranitidine, you do not need to give them another dose. Wait until the next normal dose.

What are the side effects of ranitidine?

Ranitidine is generally well tolerated by children but as with all drugs it can sometimes cause side effects. it is mainly removed from the body by the kidneys. Once given it usually lasts for about 12 hours in the blood stream.

Side effects include: Abdominal pain, constipation & nausea.

To read the full list of side effects & technical detail about ranitidine please read the following link: Summary of product characteristics

 

Omeprazole  (Also known as Losec®, Losec MUPS®)

What is omeprazole?

Omeprazole reduces the amount of acid in the stomach, which reduces the symptoms of GORD as it is the acid coming back up the food pipe that causes pain & discomfort.

What is omeprazole available as?

  • Tablets: 10 mg, 20 mg, 40 mg; these contain lactose
  • Dispersible tablets: 10 mg, 20 mg, 40 mg; these contain sugar
  • Capsules: 10 mg, 20 mg, 40 mg; these contain lactose
  • Liquid medicine can be specially ordered from your pharmacist

When should I give omeprazole?

  • Omeprazole is usually given once each day. This is usually in the morning.
  • Your doctor may have told you to give it twice a day. Give one dose in the morning and one in the evening. Ideally, these times are 10–12 hours apart.
  • Give the medicine at about the same time(s) each day so that this becomes part of your child’s daily routine, which will help you to remember.

How much should I give?

Your doctor will work out the amount of omeprazole (the dose) that is right for your child. The dose will be shown on the medicine label.

What are the side effects of omeprazole?

The evidence to date suggests that omeprazole behaves similarly in children compared to adults. The following list is some of the known side effects in adults. A complete list and full details about this drug can be found by clicking the “Summary of product characteristics”.

Common side effects(may affect up to 1 in 10 people)

  • Headache.
  • Effects on your stomach or gut: diarrhoea, stomach pain, constipation, wind (flatulence).
  • Feeling sick (nausea) or being sick (vomiting).
  • Benign polyps in the stomach.

Uncommon side effects(may affect up to 1 in 100 people)

  • Swelling of the feet and ankles.
  • Disturbed sleep (insomnia).
  • Dizziness, tingling feelings such as “pins and needles”, feeling sleepy.
  • Spinning feeling (vertigo).
  • Changes in blood tests that check how the liver is working.
  • Skin rash, lumpy rash (hives) and itchy skin.
  • Generally feeling unwell and lacking energy.
  • Fractures of the hip, wrist or spine

Rare side effects(may affect up to 1 in 1,000 people)

  • Blood problems such as a reduced number of white cells or platelets. This can cause weakness, bruising or make infections more likely.
  • Allergic reactions, sometimes very severe, including swelling of the lips, tongue and throat, fever, wheezing.
  • Low levels of sodium in the blood. This may cause weakness, being sick (vomiting) and cramps.
  • Feeling agitated, confused or depressed.
  • Taste changes.
  • Eyesight problems such as blurred vision.
  • Suddenly feeling wheezy or short of breath (bronchospasm).
  • Dry mouth
  • An inflammation of the inside of the mouth
  • An infection called “thrush” which can affect the gut and is caused by a fungus.
  • Liver problems, including jaundice which can cause yellow skin, dark urine, and tiredness.
  • Hair loss (alopecia)
  • Skin rash on exposure to sunshine
  • Joint pains (arthralgia) or muscle pains (myalgia)
  • Severe kidney problems (interstitial nephritis)
  • Increased sweating

The formula milks used in the treatment of gastroesophageal reflux disease fall into 2 main categories:

  1. Partially hydrolysed cows milk eg Nutramigen
  2. Amino acid formula eg Neocate.

The hydrolysed formulas can be thought of as a partially digested form of cow’s milk. This means that the proteins have been broken down into smaller pieces but not quite to the building blocks of the proteins which are called amino acids.

Amino acid formulas are the most pre-digested form of milk as they contain only the amino acids and no full length proteins that can cause  an allergic response.

Both these milks taste different to normal milk but babies adapt well to them. The more you digest a milk the more bitter it tastes to adults.

The following link will take you to the NICE guidelines for diagnosis and management of a child with gastroesophageal reflux disease:

NICE Gastroesophageal Refux Disease Guidelines

Dr Tim Ubhi

Review date: July 2019