Gastro-oesophageal reflux (gor)

:two_hearts::two_hearts: 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.
:two_hearts::two_hearts:There is limited evidence for use of anti-reflux medications, which should therefore be avoided.
:two_hearts::two_hearts: There is increasing evidence for the association of GOR with cow’s milk protein sensitisation

:point_right::point_right: RECOGNITION AND ASSESSMENT :two_hearts::two_hearts:Symptoms
:white_check_mark:Frequent vomiting after feeds in an otherwise healthy baby
:white_check_mark: Recurrent desaturation and/or apnoea :white_check_mark:Recurrent desaturations in ventilated babies
:white_check_mark:Chronic lung disease of prematurity may be worsened by recurrent aspiration caused by GOR

:two_hearts::two_hearts:Risk factors
:white_check_mark: Immaturity of the lower oesophageal sphincter
:white_check_mark:Chronic relaxation of the sphincter
:white_check_mark: Increased abdominal pressure
:white_check_mark: Gastric distension
:white_check_mark:Hiatus hernia :white_check_mark:Malrotation :white_check_mark:Oesophageal dysmotility :white_check_mark:Neuro-developmental abnormalities

:sparkles::sparkles:Differential diagnosis
:point_right:Suspect cow’s milk protein intolerance (CMPI)

:sun_with_face::sun_with_face:24 hr pH monitoring is of limited value in preterm babies. Consider in cases where repeated apnoea/bradycardia is resistant to other measures
:point_right::point_right:The following investigations to be considered if repeated apnoea/bradycardia, consider 24 hr pulse oximetry recordings to assess relationship to feeding
:point_right::point_right: if apnoeas/bradycardia persist at term-equivalent, consider video fluoroscopic assessment of sucking swallowing co-ordination and GOR

:white_check_mark:Position :anger::anger: Head upwards, at an angle of 30 If monitored, nurse baby prone or in left lateral position
:white_check_mark: Feeding :anger::anger: Frequent low volume feeds :anger::anger:Avoid overfeeding
:sparkles::sparkles:Gaviscon Infant® (1 dose = half dual sachet): :white_check_mark::white_check_mark: 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)
:white_check_mark::white_check_mark:bottle fed: add to ≥115 mL milk :white_check_mark::white_check_mark:nasogastric tube (NGT) fed: make up with 5 mL water and give 1 mL per 25 mL of feed
:two_hearts::two_hearts:Caution: Gaviscon Infant® contains 0.92 mmol of sodium per dose
:point_right::point_right: If symptoms persist, consider change to Instant Carobel® (will thicken with cold or hand-warm milk). :white_check_mark::white_check_mark:Add 2 scoops to 100 mL, shake well and leave for 3–4 min to thicken. Shake feed again and give immediately.

:point_right::point_right:Do not give Gaviscon Infant® and Carobel® together as this will cause the milk to become too thick

:point_right::point_right:Other measures If symptoms persist, consider other measures
:white_check_mark::white_check_mark: dairy free diet for a breastfeeding mother or trial of cow’s milk protein-free formula (in artificially fed babies)
:white_check_mark::white_check_mark: some babies with suspected CMPI are also allergic to hydrolysate and will respond to an amino acidbased formula.
:white_check_mark::white_check_mark:Some can also be allergic to the lipid in Neocate
:point_right::point_right: In severe cases with no improvement :sparkles::sparkles: 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)