Neonatal gastro-oesophageal reflux and aspiration — 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 the neonate it is almost always physiologic and self-limiting. GORD is reserved for reflux that causes complications — failure to thrive, haematemesis, oesophagitis, recurrent aspiration, or distress. This infant is thriving on the 9th centile 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 if there were bilious or green vomiting, forceful or projectile vomiting, faltering growth, visible blood in the vomit or anaemia, persistent irritability or arching, or recurrent aspiration. 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

Examiner: "The nurses want a proton-pump inhibitor. What will you do instead?" Candidate: I will not start a proton-pump inhibitor. The first step is reassurance that this reflux is normal and self-limiting, because over-treatment harms more than the reflux itself. The conservative measures are the foundation: smaller and more frequent feeds, upright positioning after feeds, careful burping, and a pacifier to stimulate swallowing. In this tube-fed preterm infant I would also review the tube position and consider switching bolus to continuous feeds, which reduces the reflux burden on impedance monitoring, and if symptoms remained troublesome I would trial an alginate, the only drug with reasonable short-term evidence in infants. [1]

Branch 3 — The reflux-apnoea link

Examiner: "What about the desaturations after feeds — is reflux causing the apnoea?" Candidate: The temporal association on a monitor does not prove causation. Reflux and apnoea are both common in preterm infants, so they frequently coincide by chance, and the randomised evidence shows that neither thickening nor alginate nor acid suppression reduces reflux-related apnoea. I would investigate the apnoea's cause rather than attribute it to reflux. [3]

Branch 4 — Evidence and prescribing

Examiner: "What is the evidence against acid suppression in infants?" Candidate: A 2023 Cochrane review found no convincing evidence that proton-pump inhibitors improve reflux symptoms in infants, and systematic reviews conclude their efficacy for infant GORD is unproven. Acid suppression is reserved for proven GORD or oesophagitis, never for physiologic reflux, and the harms are real — gastroenteritis and respiratory infection, a signal toward necrotising enterocolitis in preterm infants, and a small fracture risk with prolonged use, none of which buys benefit in physiologic reflux. [2]