Gastro-oesophageal reflux disease (GORD) – kids
- GOR is the passage of gastric contents into the oesophagus, often resulting in vomiting or ‘posseting’.
- GOR is common affecting at least 40% of infants, usually beginning before 8 weeks of age, peaks at 4 months and
- resolves by 1 year in the majority of cases.
- There is no relationship between an infant with GOR and crying or irritability.
- There is also no evidence that ‘silent reflux’ exists
distinguishing posseting, physiological GOR, and GORD
| Parameter | Posseting (normal regurgitation) | Physiological GOR | Gastro-oesophageal Reflux Disease (GORD) |
|---|---|---|---|
| Typical onset & course | < 8 weeks of age peaks ~4 months resolves ≤ 12 months | Same as posseting but larger/more frequent ‘spills’ | May begin < 6 months but persists or worsens beyond 12 months |
| Vomit characteristics | Small “milky dribbles” with burping ≤1 tablespoon | Effortless, larger volumes up to several times a day | Frequent ± forceful can be bilious or blood-stained |
| Infant behaviour | Happy contented normal feeds | Usually comfortable no distress related to feeds | Distress with or after feeds, arching/Sandifer’s apnoea cough wheeze |
| Growth & hydration | Normal weight gain normal nappies | Normal growth | Poor weight gain/failure to thrive, anaemia oesophagitis |
| Red flags / extra-oesophageal clues | None | None | Haematemesis recurrent LRTI/aspiration feed refusal, choking spells |
| Management | Reassure parents (“happy chucker”) | Feeding review, avoid over-feeding upright positioning 20-30 min post-feed consider thickened formula | Treat cause → 2-week cow-milk protein exclusion ± paediatric review acid suppression only if clear oesophageal disease |
Key take-away: posseting and simple GOR are physiologic and self-limiting; only the small minority with true disease (GORD) warrant pharmacotherapy. rch.org.aurch.org.au
Why “silent reflux” & crying/irritability aren’t diagnostic
Large studies show no causal link between reflux episodes and persistent infant distress, and the entity “silent reflux” lacks objective evidence. rch.org.aurch.org.au
Acid-suppression in infancy: evidence of harm > benefit
| Documented risk (vs no acid-blocker) | Adjusted risk ratio* |
|---|---|
| Acute gastroenteritis | ↑ 3.6-fold |
| Community-acquired pneumonia | ↑ 6.4-fold |
| Childhood fracture (dose-, age- & duration-related) | ↑ 1.6-fold |
| Clostridioides difficile infection | ↑ 5.2-fold |
| Micronutrient effects (↓ B 12, hypomagnesaemia), rebound hyper-acidity on cessation | Qualitative ↑ |
*Figures from prospective cohort & pharmaco-epidemiologic studies collated by RCH/MCRI. rch.org.aupublications.aap.org
Prescribing rule-of-thumb:
- PPIs/H₂RAs are not indicated for simple GOR.
- Trial (omeprazole 5 mg OD <10 kg) only after paediatric review when GORD is proven (oesophagitis, severe symptoms). Stop after 4 weeks if no objective improvement. rch.org.au
When it isn’t reflux – think Cow’s-milk Protein Allergy (CMPA) or lactose intolerance
| Clinical clue | CMPA more likely | Lactase deficiency more likely |
|---|---|---|
| Stool | Blood and/or mucus | Explosive watery stools perianal rash |
| Skin | Eczema urticaria | Absent |
| Family atopy | Common | Unrelated |
| Response to trial | Improves with maternal dairy-free diet or hypoallergenic formula within 1–2 weeks | Lactose-free formula resolves symptoms |
If typical CMPA features coexist with reflux-like symptoms, commence a 2-week cow-milk protein elimination trial before considering PPIs. rch.org.au
Practical bedside algorithm
- History & exam
- Confirm thriving infant with simple regurgitation → reassure.
- Identify red flags (bilious/blood-stained vomit, poor growth, apnoea, neuro signs) → urgent paediatric review.
- Optimise feeding & positioning
- Review latch/volume; smaller, more frequent feeds.
- Upright hold 20–30 min; no prone sleeping (SIDS risk).
- Trial thickened feeds (bottle-fed) if vomit volume troublesome.
- If persistent distress or complications →
- 2-week strict CMPA elimination.
- If still symptomatic and evidence of oesophagitis/aspiration → timed PPI trial, monitor, and cease if ineffective at 4 weeks.
Parent communication tips
- “Most babies ‘spit-up’; it looks messy but is rarely harmful.”
- “Medicines that block stomach acid don’t stop the milk from coming up and can increase infections and weak bones later.”
- Provide RCH factsheets and PURPLE Crying resources for coping strategies.
Bottom line:
- Posseting/GOR = common, self-resolving; no drugs.
- GORD = reflux plus harm; consider CMPA first, reserve PPIs/H₂RAs for confirmed disease only, and stop early.
AWESOME LINK: https://www.rch.org.au/uploadedFiles/Main/Content/hsru/Parent_Managing%20Unsettled%20Babies_public.pdf