GASTRO-OESOPHAGEAL REFLUX (GOR)
There is very little evidence to support a causal relationship between GOR and its assumed consequences e.g. apnoeas, respiratory distress and failure to thrive, especially in preterm babies.
There is limited evidence for use of anti-reflux medications, which should therefore be avoided.
There is increasing evidence for the association of GOR with cow’s milk protein sensitisation
RECOGNITION AND ASSESSMENT Symptoms
Frequent vomiting after feeds in an otherwise healthy baby
Recurrent desaturation and/or apnoea Recurrent desaturations in ventilated babies
Chronic lung disease of prematurity may be worsened by recurrent aspiration caused by GOR
Risk factors
Immaturity of the lower oesophageal sphincter
Chronic relaxation of the sphincter
Increased abdominal pressure
Gastric distension
Hiatus hernia Malrotation Oesophageal dysmotility Neuro-developmental abnormalities
Differential diagnosis
Suspect cow’s milk protein intolerance (CMPI)
INVESTIGATIONS
24 hr pH monitoring is of limited value in preterm babies. Consider in cases where repeated apnoea/bradycardia is resistant to other measures
The following investigations to be considered if repeated apnoea/bradycardia, consider 24 hr pulse oximetry recordings to assess relationship to feeding
if apnoeas/bradycardia persist at term-equivalent, consider video fluoroscopic assessment of sucking swallowing co-ordination and GOR
MANAGEMENT
Position 
Head upwards, at an angle of 30 If monitored, nurse baby prone or in left lateral position
Feeding Frequent low volume feeds Avoid overfeeding
Gaviscon Infant® (1 dose = half dual sachet): breastfed: give during or after a feed (add 5 mL sterile water/milk to make a paste, then add another 5_10 mL and give with a spoon)
bottle fed: add to ≥115 mL milk nasogastric tube (NGT) fed: make up with 5 mL water and give 1 mL per 25 mL of feed
Caution: Gaviscon Infant® contains 0.92 mmol of sodium per dose
If symptoms persist, consider change to Instant Carobel® (will thicken with cold or hand-warm milk). Add 2 scoops to 100 mL, shake well and leave for 3–4 min to thicken. Shake feed again and give immediately.
Do not give Gaviscon Infant® and Carobel® together as this will cause the milk to become too thick
Other measures If symptoms persist, consider other measures
dairy free diet for a breastfeeding mother or trial of cow’s milk protein-free formula (in artificially fed babies)
some babies with suspected CMPI are also allergic to hydrolysate and will respond to an amino acidbased formula.
Some can also be allergic to the lipid in Neocate
In severe cases with no improvement use only with caution: ranitidine (licensed) or omeprazole (non-licensed)
There is no evidence to support use of drugs in GOR
H2 receptor antagonists e.g. ranitidine may increase risk of sepsis or necrotising enterocolitis
(NHS guidelines)