1. Paediatric Consultant with interest in Gastro/Oncology:
The Old and the New
Dr Mark Tighe
Paediatric Consultant with interest in Gastro/Oncology:
Poole Hospital
No funding to declare

2. Aims: An update GORD including NICE guidelines
CMPA including pan-Dorset guidelines
“The views expressed in this talk are those of Mark Tighe and not necessarily those of NICE.”

3. NICE Definitions
Gastro-oesophageal reflux (GOR) = Passage of gastric contents into the oesophagus.
‘Common physiological event: can happen at any age and is often asymptomatic. More common after feeds or meals.
“Overt regurgitation”—the visible regurgitation of feeds.’
GOR +severe symptoms (such as marked distress), complications or failure to thrive = Gastro-oesophageal reflux disease.
GI complications=
Oesophagitis Haematemesis,
(Oesophageal strictures Barrett’s oesophagitis).
Extra-intestinal= Chronic respiratory disease
Chronic otitis media Sinusitis
ALTE/Apnoea Secondary anaemia

4. Natural history Infant GOR is very common;
In 40% of infants less than 3 months old.
Normally starts before 8 weeks of age
Improves with age (functional)
Oesophagus lengthens
More upright
Increased tone of lower oesophageal sphincter.
More solid diet.
only 5-10% of children have symptoms after the age of 1y.

5. GOR in older children Symptoms similar to adults
(e.g.) Recurrent epigastric pain
Heartburn.
Less likely to improve spontaneously= GORD
Oesophageal strictures from GORD in childhood reported.
Likely to respond to treatment
Evidence-based associations:
-Recurrent aspiration pneumonia
-Frequent otitis media (>3 episodes in 6 m)
-Dental erosion with neurodisability (e.g. cerebral palsy).
[Based on moderate-low quality evidence from
observational studies.]

6. Differential diagnoses
In infants:
Overfeeding (>180ml/kg/day in formula-fed infants)
Surgical: e.g. pyloric stenosis/malrotation
Cow’s milk protein intolerance
Central causes of vomiting e.g. raised ICP
Inborn error of metabolism: e.g. renal tubular acidosis
In older children
Rumination
Functional dyspepsia

7. Predisposing conditions
Neurological impairment (e.g. cerebral palsy)
Repaired oesophageal atresia (OA)
Congenital diaphragmatic hernia
Chronic lung/cardiac disease.
Prematurity

8. Diagnosis of GOR(D) Symptoms alone, Investigations if in doubt
Avoiding the need for expensive +/- harmful Ix.
Investigations if in doubt
Do not routinely investigate if the only symptom is
Unexplained feeding difficulties (such as refusing to feed, gagging, or choking)
Distressed behaviour
Faltering growth
Chronic cough
Hoarseness
Single episode of pneumonia.
[Based on high to low quality evidence]

9. Investigations:
24hr pH probe
Endoscopy/biopsy
Barium swallow
Gastric emptying scan
IgE/RAST Milk?
USS?

10. • Do not offer an upper GI contrast to diagnose /assess severity of GORD [Based on the opinion of the GDG.]
• Perform an urgent upper GI contrast for infants with unexplained bile stained vomiting (40% have a surgical pathology).
[Based on the opinion of the GDG.]
• Consider an upper GI contrast for children and young people with bile stained vomiting (persistent or recurrent).
• Offer an upper GI contrast for children and young people with a history of GORD with dysphagia.

11. Endoscopy -Haematemesis/Melaena -Dysphagia
• Refer infants, children, and young people for endoscopy if:
-Haematemesis/Melaena
-Dysphagia
-No improvement in regurgitation >1 year
-Persistent faltering growth associated with overt regurgitation
-Unexplained distress in children&young people with communication difficulties
-Retrosternal, epigastric, or upper abdominal pain that needs ongoing medical treatment or refractory to medical treatment
-Feeding aversion and a history of regurgitation
-Unexplained iron deficiency anaemia
-A referral for fundoplication
-Back arching or features of Sandifer’s syndrome.
[Based on high-low quality evidence from observational studies and opinion of the GDG.]

12. Oesophageal pH/impedance monitoring
Consider in infants, children, and young people with:
-Suspected recurrent aspiration pneumonia
-Unexplained apnoeas
-Unexplained non-epileptic seizure-like events
-Unexplained upper airway inflammation
-Dental erosion associated with a neurodisability
-Frequent otitis media
-Evaluation for fundoplication
-A suspected diagnosis of Sandifer’s syndrome.
[Based on high-low quality evidence from observational studies and opinion of the GDG.]
• Consider an oesophageal pH study without impedance monitoring in infants, children, and young people, to ascertain effective acid suppression.
[Based on the experience and opinion of the GDG.]

13. Figure 1: Example of normal 24 hour pH-probe: reflux index 2%

14. Figure 2: Example of mild acid reflux on 24 hour pH-probe: reflux index 8.9% -

15. Figure 3: Example of severe acid reflux on 24 hour pH-probe: reflux index 48%

16. Treatment of GOR
Alleviate symptoms
Promote normal growth
Prevent complications.

17. Conservative options Medical treatment Reassurance of parents
Altering infant’s positioning
Medical treatment
Altering the feed’s consistency
e.g. (Gaviscon Infant/Enfamil AR/ SMA Staydown).
Altering the gastric pH
Ranitidine/Omeprazole
Altering the motility of the gut.
Domperidone

18. For infants….
Breastfed infants with frequent regurgitation AND marked distress:
Ensure that a person with appropriate expertise performs a breastfeeding assessment
If regurgitation continues, consider trial with alginate for 1-2 weeks.
If successful continue, with regular trials off…

19. For bottle-fed infants
In formula fed infants with frequent regurgitation + marked distress :
Review the feeding history + Reduce feed volumes if excessive
Then offer a trial of smaller more frequent feeds,
Offer a trial of pre-thickened formula (prescribed)
No head-to-head trials, may be economically cheaper
If unsuccessful, stop the thickened formula and offer trial of alginate for 1-2 weeks.
If successful, continue with regular trials off.

20. Review if: Persistently projectile
Bile stained (green or yellow-green) vomiting
Haematemesis (blood in vomit)
New signs of marked distress (box), feeding difficulties, or faltering growth
No improvement beyond the first year of life.
[Based on moderate and low quality evidence from observational studies and on the experience and opinion of the GDG]

21. Do not offer proton pump inhibitors (PPIs) or H2 antihistamines [H2RA] to treat overt regurgitation only.
[Based on moderate and low quality evidence from RCTs.]
Consider a 4 week trial of H2RA or PPI for pre-verbal children or children with neurodisability with overt regurgitation AND one or more:
Unexplained feed difficulties (refusing feeds/gagging/choking)
Distressed behaviour
Faltering growth.
[Based on the experience and opinion of the GDG.]

22. For Children and young people
Consider 4 week trial of a PPI for persistent heartburn, retrosternal/epigastric pain.
[Based on moderate-low quality evidence from RCTs & the opinion of the GDG]
• Assess the response to PPI/H2 RA at 4 weeks and consider referral +/- endoscopy if
the symptoms have not resolved or recur after stopping Rx [NB rebound]
[Based on the experience and opinion of the GDG.]
• When choosing between PPIs and H2 antihistamines take into account:
-Availability/cost of age appropriate preparations
-Preference of the parent, child, or young person (as appropriate)
Offer PPI or H2RA to children &young people with endoscopy confirmed reflux oesophagitis and consider repeat endoscopy as necessary to guide treatment.
[Based on moderate-low quality RCT evidence from RCTs + the opinion of the GDG.]
• Do not offer metoclopramide, domperidone, or erythromycin to treat GOR(D) without seeking specialist advice and considering potential to cause adverse events (MHRA alert).
[Based on moderate-very low quality evidence from RCTs and opinion of the GDG.]

23. Other interventions
Consider fundoplication in infants, children, and young people with severe, intractable GORD if:
Failed medical treatment or
Feeding regimens to manage GORD are impractical— e.g. long term, continuous, thickened enteral tube feeding.
[Based on moderate and low quality evidence from observational studies and RCTs and opinion of the GDG.]

24. Cow’s Milk Protein Allergy (CMPA)

25. Background
Leading cause of food allergy in infants and young children <3 years old
Often confused with lactose intolerance, and regurgitation/reflux, colic, and constipation
Aim to set the background for Dorset-wide pathway
By the end of today:
Understand CMPA
Help identify accurately those children with CMPA
And those that don’t have CMPA!
And to help spread the word, and use this regularly!

26. CMPA Sensitivity to the protein in cow’s milk.
N.B. Normal babies often have gut dysmotility
Reflux=>Colic=>Constipation/loose stools
Often better by 1-2years
CMPA:
Symptoms can range: mild=> dramatic
Can be non-IgE or IgE mediated.
IgE mediated:
can have positive skin prick tests
+blood tests
Non-IgE: Unlikely to have positive tests
Can still be symptomatic

27. Lactose intolerance Lactose: sugar in milk/dairy
Common +transient e.g. after gastroenteritis. Rarely persists.
Varies with ethnic groups: commoner in Asian/Afro-Caribbean families. 1 in 50 Northern Europeans.
Symptoms include:
Bloating
flatulence (wind)
diarrhoea
Won’t cause blood in stools/rash/ vomiting
Children risk missing nutrients if diagnosed incorrectly.
If lactose-free trialled: lactose should be reintroduced gradually in 6 weeks.

28. “It’s all in the history…..”
History of allergic problems? □ Yes □ No  
Family history of allergic problems? □ Yes □ No  
Age of onset and relation to change in diet?
Breast to bottle? Weaning? Introduction of cow’s milk? 
What foods are causing concern? 
□ Cow’s milk □ Peanuts □ Fish □ Soya
□ Eggs □ Tree nuts □ Wheat □ Shellfish
What quantity will trigger a reaction?  
What symptoms are triggered?
Skin: Gastrointestinal:
Respiratory System:   Cardiovascular:  
What is the time course between exposure and the onset of symptoms? □ < 2 hours □ > 2 hours

29. Signs and Symptoms of possible food allergy
Signs and Symptoms of possible food allergy
Non – IgE-mediated
Slower onset – >2 hours
IgE-mediated
Rapid onset –minutes to 2 hrs
The Skin
Pruritus
Erythema
Atopic eczema
Acute urticaria (localised or generalised)
Acute angioedema (most commonly in the lips and face, and around the eyes

30. Signs and Symptoms of possible food allergy Non – IgE-mediated
Slower onset – >2 hours
IgE-mediated
Rapid onset –minutes to 2 hrs
The gastrointestinal system
Gastro-oesophageal reflux
Loose/frequent stools
Blood +/- mucus in stools
Abdominal pain/colic
Food refusal/aversion
Constipation
Perianal redness
Pallor and tiredness
Faltering growth & 1/more G.I. symptoms above (+/- atopic eczema) 
Angioedema of the lips, tongue/palate
Oral pruritus
Nausea
Colicky abdominal pain
Vomiting
Diarrhoea

31. Signs and Symptoms of possible food allergy
Non – IgE-mediated
IgE-mediated
Rapid onset – within minutes to 2 hours
The respiratory system
Upper respiratory tract symptoms – nasal itching, sneezing, rhinorrhoea or congestion (+/- conjunctivitis)
Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath
Signs and symptoms of anaphylaxis or other systemic allergic reactions

32. Red flags for referral to secondary care
Bloody stools: (especially breast fed babies)
Anaphylaxis/Angioedema/ Rapid onset Wheeze
“Vast majority of non-IgE mediated food allergy can be managed within primary care.”
Consider GP discussion/referral
Significant IgE-mediated allergy (atopy/wheeze/Urticaria)
Faltering growth
Gastrooesophageal reflux disease/resistant constipation

33. How to classify CMPA
Non-IgE mediated CMPA?
Slower onset >2 hrs
One or more of the following:
Skin symptoms
Gastro symptoms
Respiratory symptoms
IgE-mediated CMPA?
Rapid onset (minutes-2hrs)
One or more of the following:
Urticaria
Wheeze
Anaphylaxis
Refer to Paediatrician
For Urgent advice or
Rapid Access Clinic
Telephone –
Poole Hospital NHS
Foundation Trust
Bleep 0155
Allergy focused
History
If exclusive breast feeding
Check feeding technique
Strict maternal milk-free
Diet for 2-4 wks
Milk-free weaning
from 6 m
If formula feeding
EHF* for 2-4 wks
Milk-free weaning
from 6m
If mixed breast and formula
Strict maternal milk-free diet
Plus EHF for 2-4 weeks
Milk free weaning from 6m
Improvement
No improvement
Eliminate soya as well
for 2-4 weeks
If exclusive breast feeding
Re-introduce cow’s milk into
maternal diet
If symptoms return, this confirms
∆ CMPA
Restart maternal milk-free diet
Milk free weaning from 6m
If formula feeding or mixed feeding
Re-introduce cow’s milk formula
If symptoms return , this confirms
∆ CMPA
Continue with EHF
Milk free weaning from 6 months
Still no improvement
CMPA unlikely
Return to normal diet
Refer to Paediatrician
EHF=Extensively Hydrolysed
Formula

34. Reintroducing Cows Milk
At around 12 months old or 6 months after diagnosis
Re-introduce cow’s milk into maternal diet if breastfeeding
Milk reintroduction in the infant’s diet
No Improvement
Improvement
Return to normal diet
Return to milk free diet
Repeat reintroduction of cow’s
milk in 6 months
Refer for Skin Prick
Testing
if active eczema

35. Any questions?

36. Summary This is only useful if you use it!
CMPA vs lactose intolerance vs normal babies
How to spot those at risk, and when to refer
How to manage CMPA