Gastro-oesophageal reflux and reflux disease — short-answer question

Part A — Diagnosis and classification (10 marks)

a) Define gastro-oesophageal reflux and distinguish it from GORD (4 marks)

Gastro-oesophageal reflux is the effortless retrograde passage of gastric contents into the oesophagus, with or without regurgitation, and in infants it is a normal physiologic phenomenon. GORD is reflux that causes troublesome symptoms or complications — faltering growth, oesophagitis, haematemesis, recurrent aspiration, or distress that impairs quality of life — and the distinction rests entirely on the presence of these features rather than on the reflux itself. [1]

b) List the red flags that indicate this is NOT simple physiologic reflux (6 marks)

The red flags that shift the picture from physiologic reflux to GORD or to a surgical, allergic, or systemic mimic include bilious or green vomiting, forceful or projectile vomiting, faltering growth, haematemesis or occult blood with anaemia, and recurrent respiratory events suggesting aspiration. Onset after six months of age or persistence beyond the first birthday is itself atypical and should prompt a search for another cause. [1]

Bilious vomiting is the cardinal danger sign because it signals intestinal obstruction, most dangerously malrotation with volvulus, and it demands urgent upper gastrointestinal contrast imaging and surgical review rather than anti-reflux therapy. This infant has none of these features, so this is physiologic reflux. [1]

Part B — Management and evidence (10 marks)

a) Outline the stepwise management for this infant (6 marks)

Begin by confirming that this is physiologic reflux: the infant is thriving on the 50th centile with effortless posseting and no red flags, so the first step is reassurance that reflux is normal, expected, and self-limiting. Explain that over-treatment causes more harm than the reflux itself. [1]

The conservative measures are the foundation: feed smaller volumes more frequently, avoid overfeeding, keep the infant upright after feeds, and wind carefully. As a formula-fed infant with crying and arching, a two-to-four-week trial of an extensively hydrolysed formula is appropriate to exclude cow's milk protein allergy before any drug. If troublesome symptoms persist a short alginate trial is the pharmacological option with the best short-term evidence, and it should be reassessed and stopped if ineffective. [1]

b) What is the evidence for and against acid suppression in this infant? (4 marks)

Acid suppression is not indicated. A large placebo-controlled trial of lansoprazole in symptomatic infants found no benefit over placebo for crying and reflux symptoms, with more lower respiratory tract infections in the treated group, and systematic and Cochrane reviews conclude that proton-pump-inhibitor efficacy for infant GORD is unproven. [2] [3]

Proton-pump inhibitors in infants carry real harm — gastrointestinal and respiratory infection and, with prolonged use, a small fracture risk — none of which buys benefit in physiologic reflux. Acid suppression is reserved for proven oesophagitis or strongly suspected GORD, and an empirical trial is not a valid diagnostic test in an infant of this age. [3] [1]