1. Gastroesophageal reflux Definition: Retrograde flow from stomach into oesophagus Does not have to present at mouth

2. Maturation aspects Oesophagus clearance mechanisms "Physiological reflux" Most resolve spontaneously by 1 - 4 yrs

3. Iatrogenic causes of reflux Gavage feeding and tubes

4. Problematic reflux incidence 1 in 300 to 1000 children 90% before 6 weeks age Untreated, 10% complications

5. Predisposition Cerebral palsy Tubes in seriously ill patients

6. Defective LES Motility Abnormal neural control of LES Transient Lower Oes. Sphinct. relaxation GER Oesophagitis Gastric distension Hiatus Hernia

7. Mode of presentation I Simple regurgitation, thriving Vast majority No treatment Regurgitation with failure to thrive Loss of nutrients

8. Mode of presentation II Regurgitation with respiratory symptoms Recurrent pneumonia Persistent cough Wheezing Aspiration Vagus mediated Apnoea attacks Regurgitation with complication Anaemia from blood loss Stricture formation

9. Diagnosis Think of it Upper GI barium series Intra-oesophagus pH monitoring Radio-nuclear scintigraphy "milk scan“ Oesophagoscopy Biopsy

10. Management Feeding and post-feeding position : prone, elevate Change feeding pattern : frequent small feeds, thicken feeds : Nestargel/ gelatine H2 receptor antagonists, proton pump inhibitors : antacid : reduce acid, heal oesophagitis Prokinetic agents: cisapride (off the market), domperidone or metoclopramide before meals Surgery