Gastro-oesophageal reflux and reflux disease — structured oral (viva)

Branch 1 — Definition and classification

Examiner: "Is this reflux or GORD, and what separates the two?" Candidate: This is physiologic gastro-oesophageal reflux. GOR is the effortless retrograde passage of gastric contents into the oesophagus, and in infants it is a normal, self-limiting developmental phenomenon. GORD is reserved for reflux that causes troublesome symptoms or complications — faltering growth, oesophagitis, haematemesis, recurrent aspiration, or distress impairing quality of life. This infant is thriving with effortless posseting and no red flags, so this is physiologic reflux, not disease. [1]

Examiner: "What red flags would change your mind?" Candidate: I would reconsider with bilious or green vomiting, forceful or projectile vomiting, faltering growth, haematemesis or anaemia, or recurrent aspiration. Late onset after six months or persistence beyond the first birthday would also make me look for another diagnosis. Bilious vomiting is the cardinal danger sign — it signals intestinal obstruction, most dangerously malrotation with volvulus, and it needs urgent contrast imaging and surgical review, not anti-reflux therapy. [1]

Branch 2 — Management and the failed PPI

Examiner: "The proton-pump inhibitor has not helped. What will you do?" Candidate: I would stop the proton-pump inhibitor, because it is not indicated and its failure to help is expected. The first step is reassurance that reflux is normal and self-limiting. I would optimise feeding with smaller, more frequent volumes, avoid overfeeding, and use upright positioning and careful winding. As this is a formula-fed infant with crying and arching, I would trial an extensively hydrolysed formula for two to four weeks to exclude cow's milk protein allergy, and if symptoms remained troublesome I would trial an alginate, the drug with the best short-term evidence in infants. [1]

Branch 3 — Excluding the mimics

Examiner: "What are you most worried about missing?" Candidate: Cow's milk protein allergy is the mimic I would actively exclude, given the crying and arching, and it responds to a hydrolysed formula trial. I would also make sure I have not missed a surgical cause such as malrotation in any bilious vomiter, pyloric stenosis in a projectile vomiter, or a systemic cause such as urinary tract infection or raised intracranial pressure. In an older child with dysphagia or food impaction I would consider eosinophilic oesophagitis, which needs endoscopy and biopsy rather than acid suppression. [1]

Branch 4 — Evidence and prescribing

Examiner: "What is the evidence against acid suppression here, and what about prokinetics?" Candidate: A large placebo-controlled trial of lansoprazole in symptomatic infants found no benefit over placebo and more lower respiratory infections in the treated group, so proton-pump inhibitors are not indicated for infant crying, arching, or physiologic reflux, and an empirical trial is not a valid diagnostic test. Prokinetics such as domperidone are not recommended for routine use because their efficacy is weak and they carry a risk of QT prolongation and cardiac arrhythmia. The safest and most effective interventions here are reassurance, feeding optimisation, and exclusion of cow's milk protein allergy. [2] [3]