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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

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GORD in Infants and Children

gerdWHAT IS THE DIFFERENCE BETWEEN GOR AND GORD?
Gastro-oesophageal reflux disease (GORD/ GERD)* is a more serious form of gastro-oesophageal reflux (GOR/GER)*. It can happen to people of all ages and if left untreated, it can lead to more serious health problems. It is important to distinguish between normal, physiologic reflux (GOR) and GORD in children.
The act of refluxing is a normal process that virtually everyone does at times. If your child is refluxing frequently, your doctor may diagnose them with a medical condition called GOR, which tends to present as regurgitation or posseting. This problem generally peaks between 1-4 months of age, and usually resolves itself by 12-18 months. For many children and their families, GOR causes no major problems and can easily be controlled with simple remedies. Most children and infants with GOR, are happy and healthy, even if they spit up or vomit frequently.
When reflux causes complications or long term problems, and is unresponsive to lifestyle measures, it may be diagnosed as GORD. GORD can be very distressing for children and their families. Medical intervention is often required, in the form of medication and possibly further investigations.
WHAT EXACTLY IS GORD?
GOR also known as acid reflux or acid regurgitation; occurs when the lower oesophageal sphincter (LES) opens spontaneously or doesn't close properly, and stomach contents rise up into the oesophagus. The oesophagus is the tube that carries food from the mouth to the stomach. The LES is the ring of muscles at the bottom of the oesophagus, and acts as a valve between the oesophagus and stomach. One of the symptoms of acid reflux is that food or fluid can be tasted in the back of the throat or mouth. Acid indigestion or heartburn occurs when refluxed stomach acid touches the lining of the oesophagus, causing a burning sensation. Occasional GOR is common but persistent reflux that occurs more than twice a week is considered GORD.
CAUSES:
Babies and young children are more likely to get GORD if:
The oesophageal sphincter (the ring of muscles at the bottom of the oesophagus) is underdeveloped. This is more common in premature babies.
The stomach gets too full.
Food moves too slowly down the oesophagus.
They have a hiatus hernia, in which part of the stomach gets pushed into the chest, through a gap in the diaphragm (a large, thin muscle that separates the lungs and the stomach).
They are overweight. Excessive fat in the abdominal cavity increases the pressure inside it. This causes stomach contents to travel up into the oesophagus.
They are constipated. Constipation increases the tendency to reflux by raising pressure inside the stomach cavity.
Cerebral palsy, Down syndrome and other severe neuro developmental problems are associated with reflux.
DIAGNOSIS:
GORD can often be diagnosed on the basis of a clinical diagnosis. Children or infants with GORD usually present with frequent and troublesome regurgitation and vomiting (even up to 2 hours after a feed). This is generally accompanied by frequent and troublesome crying, irritability or back-arching during or after feeding; or feeding or food refusal (despite being willing to suck on a pacifier, if used).
Your doctor may ask you to keep a food diary, to monitor your child's food intake, and how often they are vomiting or regurgitating their food. You may need to weigh your child regularly or have them weighed at a clinic, to ascertain if they are losing or gaining weight.
If your child's symptoms are unresponsive to treatment, further testing may be required:
Ambulatory acid (pH) probe tests can be used to determine if and for how long stomach acid comes into contact with the oesophagus for. These tests therefore provide an indication of the extent of the acid reflux. One type of pH test, involves threading a thin wire with an acid sensor at the end, through the nose into the oesophagus. The sensor is connected to a wearable monitor that records the amount of acid produced over a 24 hour period. A similar acid probe test, involves inserting a wireless acid monitor into the oesophagus. The monitor sends signals to a computer, worn around the waist for a 48 hour period. Thereafter, the monitor falls off and is painlessly eliminated. These tests are useful if combined with a carefully completed food diary (i.e. when, what and how much your child eats) - which allows your doctor to establish correlations between symptoms and reflux episodes. They may also be helpful in establishing whether respiratory symptoms, such as wheezing and coughing, are triggered by reflux.
Upper GI X-rays help to measure the length and shape of the oesophagus and upper stomach.
Your doctor may order a motility study, in which a catheter is inserted through your child's nose and into their stomach. This test is useful as it measures the movement and pressure in the oesophagus (peristalsis) and the strength of the valve between the oesophagus and stomach.
Upper endoscopy can help diagnose most cases of acid reflux. A thin flexible tube with a camera at the end is inserted into the mouth and is used to visually examine the oesophagus, stomach and upper part of the small intestine. This test is usually done under light sedation. A biopsy may be taken from the oesophageal tissue. Tissue analysis reveals any damage caused by acid reflux and rules out the presence of infection or abnormalities of the oesophagus.
Despite the availability of tests, it must be borne in mind, that half of all GORD sufferers have no visible signs of the disease.
ADDITIONAL SYMPTOMS OR COMPLICATIONS OF GORD:
Oesophageal symptoms:
Haemataemesis- the act of vomiting blood, often due to bleeding in the oesophagus, stomach or duodenum.
Anaemia- can result from an oesophagus that is bleeding and painful.          
Children who experience this complication may cough up blood.
Failure to thrive- failure to grow and develop at the usual rate for the child's
age.
Dysphagia- frequent choking after feeding.
Sandifer-Sutcliff syndrome- abnormal posturing after feeding, with tilting or        
torticollis of the head and bizarre contortions of the trunk.
Oesophagitis- the stomach produces acid to help break down food. When
this partly digested food goes back up into the oesophagus due to reflux, its acidic nature can make the oesophagus sore and inflamed.
Respiratory symptoms:
Coughing, wheezing, asthma, or reactive airway disease.
Stridor, hoarseness, recurrent croup, or laryngomalacia (A condition occurring in small children that is characterized by breathing difficulties and stridor. It is caused by flaccidity of the larynx and generally resolves                
spontaneously by age 2).
Bronchitis or aspiration pneumonia
Sinusitis
Recurrent otitis media
History of apnoea (cessation of breathing) or apparent life-threatening      
events
Other symptoms:
Sleep difficulties
Dental erosions
Hiccups
Bad breath
WHEN TO SEE YOUR DOCTOR:
Seek medical advice if your child or infant; is very irritable, cries excessively or is inconsolable; appears to be in pain; sleeps poorly and is easily disturbed; losses weight or fails to thrive; develops hoarseness; or appears to be refluxing frequently.
Your child complains of; food or fluid coming into the back of their throat or mouth; heartburn or a painful feeling in their stomach or centre of their chest; swallowing difficulties or pain on swallowing; or the sensation that their food is stuck.
Your infant or child's vomiting; is forceful; frequent; increasing in amount; is of a large volume; contains coffee ground-like material or is black, red or brown; or is green or yellow.
When feeding, your child or infant; refuses to feed or eat; pulls off the bottle or breast or frequently interrupts the feed; finds it difficult to reattach to the bottle or breast; frequently chokes or gags; arches their back, draws their legs up and screams; is fussy or sensitive to different textures; or complains of pain.
If your child or infant is having any breathing or chest issues, visit your doctor immediately. These may include; an increased effort to breathe, particularly after vomiting or during or after eating; repeated coughing; wheezing; recurrent chest infections or pneumonia; apneas (breathing stops briefly); cyanosis (turns blue) around the mouth or face.
REFLUX IN OLDER CHILDREN:
As infants and children get older, their reflux symptoms may change. Parents sometimes report that even if their child seems to have outgrown reflux, it tends to recur in times of stress. For example, when starting a new school, during exams, if they are teething, ill or go for a vaccination.
Older children may also verbalize that they feel unwell, and complain that their tummy/ throat hurts or that they have a yucky taste in their mouths. Children with GORD sometimes present with behavioural, eating and sleep issues. Behavioural problems may include; extreme or age inappropriate temper tantrums, excessive sensitivity or irritability, clingy or demanding behaviour, self-injurious behaviours (e.g. head banging, obsessive nail biting, biting themselves), or losing the plot over small issues. Associated eating difficulties include; pain when swallowing, food aversions, the refusal to eat certain meals or a preference to snack rather than eat meals, the need for frequent drinks of water or a preference for drinking rather than eating in general. Sleep issues that have been reported include; not liking lying fat, waking up feeling tired and irritable, frequent night waking and asking for fluids at night, and difficulties falling asleep. Children with reflux may be pale in appearance, suffer from motion sickness, appear to be in pain (e.g. doubled over or holding their stomachs), burp frequently, appear tired and lethargic, have dental erosions, or have a hoarse voice especially on awakening.
TREATMENT:
LIFESTYLE MODIFICATIONS:
There are a number of simple strategies you can use to ease your infant or child's discomfort, if they regularly experience reflux-related symptoms. Lifestyle modifications are generally the first line of treatment for GORD:
Burp your infant several times during a feed and keep them in an upright position after a feed.
If your baby is bottle fed, you can minimize the likelihood of them vomiting or bringing up their food, if you thicken their feeds. Thickened feeds also tend to help with choking or gagging. Thickened feeds can't be used for breast fed babies. They are more likely to cause coughing, weight gain and possible diarrhea.
Give your child smaller, more frequent meals.
Avoid giving your child foods and drinks that tend to aggravate reflux symptoms; such as cold drinks, chocolate, peppermint, spicy food, acidic food like oranges, tomato and pizza, or fried or fatty foods.
Ensure that your child eats 2-3 hours before bedtime and encourage them not to lie down immediately after eating.
If your child sleeps with their head higher than the rest of their body, it makes it more difficult from their stomach contents to get up into their oesophagus. It is insufficient to raise your child's head just with pillows rather secure wooden blocks under the bedposts.
In a small number of children, persistent regurgitation or vomiting is the result of an allergy to cow's milk. Breastfeeding moms may be advised to eliminate dairy products from their diets for two weeks. In older children or babies who are eating solids, dairy products should also be avoided for 2 weeks. A significant improvement in symptoms would warrant an appointment with a dietician to guide you and your child, on how to eat a balanced, dairy-free diet.
MEDICATION:
Infants and children are less likely to bring up their food if they have a supplement called sodium alginate mixed with their food or dissolved in their water after their feeds. This medication forms a gel in the stomach to stop acid and food from going back up into the oesophagus. Sodium alginate is generally free of side-effects, but you should consult your doctor before using this treatment, especially if your child is younger than 12 months. This medication should not be given to premature babies, unless specifically prescribed by a doctor; to babies who are feverish, have diarrhea and are vomiting a lot, due to its high sodium content; or to children whose feed is already thickened.
A medication called metoclopramide may be prescribed in extreme cases, for children who have severe vomiting that won't stop. This medication reduces the symptoms of GORD but is associated with muscle spasms. Metoclopramide works by tightening the muscles of the oesophageal sphincter, so that food and liquids are less likely to re-enter the oesophagus from the stomach.
H2 blockers are often used to treat heartburn and indigestion in adults (e.g. Tagamet, Zantac). These medicines reduce the amount of acid in the stomach, so that less acid goes up into the oesophagus and causes painful heartburn. The effects of these medications on GORD in children, is uncertain, so talk to your doctor before giving them a try.
Proton pump inhibitors are effective in relieving the symptoms of GORD and help heal the oesophageal lining. These are recommended for children with severe reflux only.
SURGERY:
Anti-reflux surgery needs to be considered if: symptoms are unresponsive to both lifestyle modifications and medication; your child will require lifelong treatment; they are unable to take medication regularly; or they have serious complications, such as Barrett's oesophagus or the narrowing of the oesophagus, making swallowing difficult.
Surgery will only be performed after a thorough examination to determine the extent of the damage to the oesophagus and to ensure that your child's reflux will be helped by surgery.
Most cases of GORD are related to the lower oesophageal sphincter. Normally these muscles relax to allow food and liquids into the stomach, then close tightly so that the stomach contents cannot move back upwards. If the oesophageal sphincter is weak or relaxes at the wrong time, stomach acid flows back up into the oesophagus. Nissen fundoplication is the most frequently performed anti-reflux surgery. It is minimally invasive and has a high success rate. The procedure involves wrapping the top of the stomach around the outside of the lower oesophagus, so as to tighten the lower oesophageal sphincter.
The procedure usually involves a 2 day hospital stay and your child will be able to resume their normal activities after 1-2 weeks. Swallowing difficulties post-op are common, but generally improve after the first few months. Your child may also experience belching, bloating and diarhoerria. 90% of people find that they are heartburn-free, 1 month after this operation.
CONCLUSION
Gastro-oesophageal reflux disease (GORD) is a common and chronic gastrointestinal disorder. 80% of the population will suffer from reflux at some stage in their lives. GORD occurs when the lower oesophageal mucosa is exposed to stomach contents for a prolonged period of time. This results in heartburn, regurgitation and waterbrash (excessive saliva in the mouth). Symptoms may be exacerbated by lying flat or consuming certain foods (fatty foods) and beverages (hot drinks). Unfortunately symptom severity and the amount of damage done to the oesophagus do not always correlate. It is therefore imperative that your child see a doctor, and undergo a proper investigation. GORD often requires lifelong management and anti-reflux therapies. The aim of treatment is threefold; to heal the scarred/ damaged oesophagus; to prevent serious complications, such as Barrett's oesophagus or strictures (narrowing); and to alleviate symptoms so as to improve quality of life. Since there is no ideal method of treating reflux in children, discuss the pros and cons of all treatment options with your health care provider. In most cases, reflux symptoms resolve spontaneously by 18 months, so it is unnecessary for your child to undergo extensive investigations and multiple drug therapies before this time. This will help to avoid unnecessary side-effects from unnecessary treatments. However, since severe reflux symptoms can result in serious complications, decisions should be made on an individual basis. Learning more about your child's condition, may help allay some of your fears in this regard and help to improve your families quality of life.
The terms GOR/GER and GORD/GERD can be used interchangeably and do refer to the same conditions.
http://www.refluxinfo.co.uk

http://www.mayoclinic.org

http://www.webmd.boots.com/default.htm

http://www.patient.co.uk/

http://www.cks.nhs.uk

http://digestive.niddk.nih.gov/

http://wwww.reflux.org.au/