Managing GORD

 Managing Gastro-oesophageal Reflux Disease (GORD)

This page was previously called “Managing Silent Reflux”.  Silent Reflux is a term that we are no longer using – Laryngopharyngeal Reflux is the correct term.

GORD causes stomach acids to be “refluxed” into the oesophagus/throat and cause inflammation and discomfort/pain, or other complications such as feeding or breathing problems.  There may or may not be spilling or vomiting.

Roslyn Ballantyne (RN), National Coordinator, Gastric Reflux Support Network New Zealand for Parents of Infants and Children Charitable Trust (GRSNNZ) December 2013.

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  The information provided on Crying Over Spilt Milk is designed to support, not replace the relationship that exists between a patient/site visitor and his/her existing physician. Please do not change medical treatment without first consulting a personal health professional.
Please note that GRSNNZ does not provide advice on dosages of complementary or conventional medications.

General Management Techniques

Winding/burping regularly (preferably high on the shoulder with a nice straight body to allow the wind to escape more easily).

Avoid pressure on tummy except for during “tummy time”.  (Tummy time is important and newborns should have this at least once a day: http://www.plunket.org.nz/your-child/newborn-to-6-weeks/play-and-learning/)

Sleep pattern in place.

Avoid “crying it out” as crying worsens gastric reflux and is distressing to family. Bad sleep behaviours do not develop and sleep patterns are easily established once gastric reflux is adequately controlled.

Pacifier/dummy? (This is only an option if LMC and Parents are comfortable with it.  Consider latch and milk supply issues.) Sucking gives comfort but feeding continuously may exacerbate or encourage more GOR episodes.  See Dummy or no dummy? by Pinky McKay on Essential Mums for pros and cons.
Wind preparation like Weleda colic powder (this can help with wind if baby wakes early and is uncomfortable. 10 ml boiled water or Weleda colic powder in 10 ml of water can wash the oesophagus, bring up remaining wind and allow baby to return to sleep).

AND

BREASTFED

Try a dairy-free diet for Mum for up to two weeks*

AND

Check latching/feeding,flow of milk and position

Not working?

BOTTLE-FED

Try an alternative to standard cow’s milk  based formula for one week**

Not working?

If you haven’t already, you need to take your baby to a doctor for a proper diagnosis if you think they may have gastric reflux and it is a problem.

The doctor may or may not prescribe medication.

Prescribed medication not working or you are concerned about your baby?

See your doctor again.  Maybe a referral to a paediatrician is appropriate?

(In most areas of NZ, children will only be seen by publicly funded paediatricians for GORD if there are severe concerns about their health or growth. For this reason, you may need to pay to see a private paediatrician if your baby/child requires treatment outside of your GP’s area of expertise.)

Prescribed medication not working?

Can dosage be increased??

(Please see your doctor or paediatrician to discuss.)

Not working?

Can medication be changed or another one be added?
(See your doctor or paediatrician for a review.)

Not working?

BREASTFED
Gluten free diet for mum for up to one week*
BOTTLE-FED
Next step

Not working?

Tests needed?

pH study to evaluate the presence and extent of reflux

Barium swallow to rule out anatomical abnormalities

Coeliac screen, allergy testing or consideration of food intolerances if appropriate

Gastroscopy to evaluate the presence and extent of reflux oesophagitis

Tests confirm reflux oesophagitis??
(With no evidence of food allergies/intolerances and/or no response to change in diet.)

YES

Consider fundoplication surgery

NO

Consider other possibilities for symptoms, food allergies and intolerances, delayed gastric emptying, coeliac disease, learnt behavioural patterns, side effects of medications, other motility disorders etc. etc.

 

  • Testing may be appropriate at any time throughout this process.

  • More than one treatment option or test may be recommended at any one time as each child’s family history, gastric reflux symptoms or combination of symptoms may differ, and indicate the need to quicken the process of getting symptoms under control (e.g. failure to thrive) or indicate the need for a different approach (e.g. family history of coeliac disease).

  • If you have a child who gets both pain from reflux and vomits/spills, you will need to refer to the charts showing treatment options for both “GORD” and the “Happy Chucker”.

  • However, an important point to note is that with babies who get pain from reflux as well as vomit, it is important to control the pain and acid first before considering the use of thickeners or thickened formulas. When the pain/acid is under control with appropriate acid reducing medications, then try the options on the “Happy Chucker” chart. Babies who get pain due to reflux may have some degree of oesophagitis (inflammation/ulceration of the oesophagus). Studies have shown that although thickeners and thickened formula may reduce the number of episodes they prolong the length of time of the remaining episodes as thickened fluid does not drain as well from the oesophagus. It is these prolonged reflux episodes, when they contain acid that can do the most damage.  However, with the move away from prescribing for GORD by many Health Professionals unless there appears to be significant pain, severe complications, growth issues or difficulties feeding it may be appropriate to discuss thickeners with your Health Professional (doctor, Well Child Provider or dietician).

*The time frames mentioned for these diets are the length of time that the diet should be trialled for by the breastfeeding mother before deciding that they are not helping and before returning to a normal diet. The dairy free diet and/or gluten free diet needs to be a complete removal of these foods as cheating does matter. A positive response may be seen earlier than the time frame indicated. If the baby has started solids then these also need to be free of dairy and/or gluten. If the diet is successful in resolving symptoms then it needs to be continued or another form of feeding considered. Breastfeeding is nearly always best for the baby with gastric reflux but the mother’s health is also important, so consider this decision carefully with the help of a paediatrician for future feeding options.

**For advice on  an alternative to standard cow’s milk  based formula, please discuss which formula to choose with your Health Professional (doctor, Well Child Provider or dietician) or phone Nutricia on 0800 258 268 to speak to a Dietician.  If the baby has started solids then these also need to be free of dairy.

Mother, Baby

NB:  Raising the head of the bed is no longer recommended and studies have shown that “head elevation may not always be of clinical value“.  http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284.full.pdf and http://www.changeforourchildren.co.nz/files/docs/infant%20positioning%20and%20reflux.pdf  Some health professionals still recommend raising the head of the bed and we would advise that you should only do this after discussion with your own health professional.

 

© Gastric Reflux Association for the Support of Parents/babies (GRASP) and Crying Over Spilt Milk Gastric Reflux Support Network New Zealand for Parents of Infants and Children Charitable Trust (GRSNNZ) 2005. Used and edited with permission by Roslyn Ballantyne (RN), Regional Coordinator, GRSNNZ (in consultation with Dr Rodney Ford, Paediatrician) May 2005 and Jennifer Howard, National Coordinator, GRSNNZ September 2011.  Last updated by Roslyn Ballantyne, National Coordinator, September 2015.

Page may be printed or reproduced for personal use of families or health professionals, as long as copyright and Crying Over Spilt Milk‘s URL are included. It may not be copied to other websites or publications without permission and acknowledgement. This information (unedited) was also provided (by GRASP) to health professionals in New Zealand to use “to continue to support and inform families with babies/children with Gastro-oesophageal Reflux.”