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1

What is the difference between GOR, GORD and regurgitation?

Gastro-oesophageal reflux (GOR) = passage of gastric contents into the oesophagus

Gastro-oesophageal reflux disease (GORD) = presence of troublesome symptoms or complications arising from GOR.

Regurgitation/posseting = is the voluntary and involuntary movement of part or all of the stomach contents beyond the oesophagus

2

Why are infants prone to reflux?

Short, narrow oesophagus.
Delayed gastric emptying.
Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm.
Liquid diet and high caloric requirement, putting a strain on gastric capacity.
Larger ratio of gastric volume to oesophageal volume.
recumbent posture

3

What are the risk factors for GORD in infants

premature
FH of heartburn or acid regurg
obesity
hiatus hernia
history of diaphragmatic hernia or congenital oesophageal atresia
neurodisbility
overfed!!!

4

What are the features of a child with reflux

distressed
crying whilst feeding
abnormal neck postures
chronic cough
hoarse
feeding difficulties - refusal, gagging, choking
failure to thrive
aspiration pneumonia

5

What age has reflux normally developed by?

6 months
if symptoms start after this, probably not reflux!

6

What are some differentials for reflux and what sets them apart?

pyloric stenosis - projectile vomiting, <2m old
obstruction - bilious vomiting, abdo distension and tenderness
upper GI bleed - heamatemesis
sepsis - unresponsive, focal features of infection
cow's milk protein allergy - blood in stool, atopy, diarrhoea

7

How is regurgitation managed

reassure parents that it is normal!
make sure they seek help if child becomes distressed, feeding problems develop or faltering growth

8

How is GORD managed in a breast fed infant

trial giving gaviscon diluted in water after each feed for 1-2 weeks
if helps, continue

if not, try H2 antagonist or PPI for one month

if fails, seek help of paediatrician

9

How is GORD managed in a bottle fed infant

if feeds are excessive, decrease amount of milk!

1-2 weeks trial of giving smaller feeds more often (maintaining adequate intake)

if not resolved, 1-2 weeks of thickened feed

if not resolved, 1-2 weeks of gaviscon mixed in with feed

if not resolved, try H2 antagonist or PPI for one month

if fails, seek help of paediatrician

10

What is the daily milk requirement of an infant

150ml/kg per day

11

What are some complications of GORD

Reflux oesophagitis.
Recurrent aspiration pneumonia.
Recurrent acute otitis media (more than three episodes in 6 months).
Dental erosion in a child with neurodisability (for example cerebral palsy).
Apnoea

12

What is pyloric stenosis

diffuse hypertrophy and hyperplasia of the smooth muscle cells of the antrum and pylorus leading to narrowing of the pyloric canal and causing gastric outlet obstruction

13

What are the risk factors for pyloric stenosis

male
FH

14

What are the features of pyloric stenosis

infant aged 2-8 weeks
vomiting after feeds - projectile, non-bilious, remians hungry and wants more!
lethargy
dehydration
infrequent/absent bowel movements
weight loss

15

What might be found on examination in an infant with pyloric stenosis

Stomach wall peristalsis

An enlarged pylorus, classically described as an 'olive', may be palpated in the right upper quadrant or epigastrium of the abdomen.

16

What is the differential diagnosis for an infant with suspected pyloric stenossi

gastroenteritis
food allergy
over feeding
GORD
sepsis
UTI
malrotation - would be bilious vomiting

17

What investigations would you do in a child with suspected pyloric stenosis

blood gas
U+E
USS abdomen

18

What is classically seen on a blood gas in an infant with pyloric stenosis? Why is this?

hypokalaemia, hypochloraemic metabolic alkalosis

due to the loss of hydrochloric acid with the repeated vomiting of stomach acid causing a hypochloraemia and metabolic alkalosis.

The kidneys will then exchange potassium to retain protons to attempt to compensate, leading to a hypokalaemia

19

What is the management of pyloric stenosis

pre op:
correct hydration and electrolyte abnormalities
NG tube - not for feeds, but aspirated at 4 hourly intervals

operatively: Ramstedt’s pyloromyotomy

post op: recommence feeds 6 hours after op

20

How is Ramstedt’s pyloromyotomy carried out?

open (supra-umbilical incision) or laparoscopic

pyloric muscle divided down to the mucosa

21

What are some pre op and post op complications of pyloric stenosis

pre op: hypovolaemia, apnoea

post op: infection, bleeding, wound dehisence, perforation, incomplete myotomy leading to persistent vomiting

22

Why can an infant vomit post Ramstedt’s pyloromyotomy

gastric distension
dysmotility
incomplete myotomy.

23

What is intussusception and why does it lead to obstruction

one section of bowel invaginates into a distal section of bowel
mesentery becomes compressed as it is drawn between the layers
lymphatic and venous obstruction leads to ischaemia
therefore, bowel wall distends and obstructs lumen
peristalsis is disrupted
OBSTRUCTION!!!

24

When is intussusception most common?

aged 5-10 months

25

What causes intussusception to occur?

90% - non-pathological lead point eg. rotavirus, adenovirus, HHV6, amoeba, shigella

10% pathological eg. Meckel's diverticulum (75%).
Polyps and Peutz-Jeghers syndrome (16%).
Henoch-Schönlein purpura (3%).
Lymphoma and other tumours (3%).
Reduplication - a process by which the bowel wall is duplicated (2%).
Cystic fibrosis.
An inflamed appendix.
Ascariasis.
Nephrotic syndrome.
Foreign body.
Hyperperistalsis.
Exclusive breast-feeding.
Weight above average.
Rotavirus vaccine.
Abdominal tuberculosis.

26

What are the symptoms of intussusception

sudden onset of colicky abdo pain
paroxysmal - every 20mins
vomiting
dehydration
lethargy, irritability, hypotonia, reduced conscious level

27

What can be found on examination in intussusception

sausage shaped mass in RUQ
lack of bowels in RLQ - Dance's sign

28

What investigations should be done in suspected intussusception

U+E, FBC, clotting,
USS, AXR

29

What are the management options for intussusception

drip adn suck firstly - for dehydration

radiologist managed reduction by air or barium enema - if no sign of peritonitis, perforation or shock.

if any sign of peritonitis, perforation, pathological lead point >24 history or failed enema, laparotomy is needed!

30

What is CMPA

cow's milk protein allergy
immune mediated abnormal allergic response to harmless proteins in milk