• Gastro-oesophageal reflux (GOR) is a normal physiological process
• GORD occurs when the effect of GOR leads to symptoms severe enough to merit medical treatment
• There is very little evidence to support a causal relationship between GORD and its assumed consequences e.g. apnoeas, respiratory distress and failure to thrive, especially in preterm babies
• There is also limited evidence for use of anti-reflux medications, which should therefore be avoided. There is evidence for the association of GORD with cow’s milk protein sensitisation 

Symptoms which could suggest GORD

• Frequent vomiting after feeds in an otherwise healthy baby 
• Recurrent desaturation and/or apnoea
• Recurrent desaturations in ventilated babies [exclude bronchopulmonary dysplasia (BPD) spells]
• Chronic lung disease of prematurity may be worsened by recurrent aspiration caused by GORD

Risk factors

• Immaturity of the lower oesophageal sphincter
• Chronic relaxation of the sphincter
• Increased abdominal pressure
• Gastric distension
• Hiatus hernia
• Malrotation
• Oesophageal dysmotility
• Neurodevelopmental abnormalities

Differential diagnosis

• Suspect cow’s milk protein intolerance (CMPI) in babies who are formula milk fed or have fortifier added to maternal breast milk, and have recurrent vomiting/irritability/apnoeas despite appropriate management of GORD

• 24 hr pH monitoring is of limited value in preterm babies. Consider in cases where repeated apnoea/bradycardia is resistant to other measures
• Following investigations to be considered after discussion with consultant:
  • if repeated apnoea/bradycardia, consider 24 hr pulse oximetry recordings to assess extent of problem and relationship to feeding 
  • if apnoeas/bradycardia persist at term-equivalent, consider video fluoroscopic assessment of sucking-swallowing co-ordination and GORD
  • in severe cases, referral to gastroenterology may be appropriate for consideration of upper GI endoscopy or barium swallow investigation

Position

• Head upwards, at an angle of 30°
• Nurse baby prone or in left lateral position, if they are monitored
• Consider involvement of occupational therapy and/or developmental care team to ensure appropriate responses to stress and behavioural cues are not misinterpreted 

Feeding

• For formula fed babies, try frequent low volume or continuous feeds
• Babies ≥34 weeks': consider Instant Carobel® according to manufacturer’s instructions (take care that thickened liquid does not block fine bore NGT) 
• Babies >34 weeks’ gestation: if no improvement with feed thickener, consider an alginate (Gaviscon Infant®) according to manufacturer’s instructions (1 dose = half dual sachet)
• Review every 14 days 

Other measures

• If symptoms persist, consider other measures after discussion with consultant.
  • dairy free diet for a breastfeeding mother or trial of cow’s milk protein-free formula (in artificially fed babies). If trial commenced, continue for ≥2 weeks with careful symptom monitoring 
  • assessment by speech and language therapy team for those with ongoing or unusual symptoms would be appropriate such as:
    • poor co-ordination of suck and swallow
    • longer than expected time to transition to oral feeding
    • aspiration
• Babies requiring specialist formulas should be supported by local dietetic services

• GORD in preterm babies is common and parents can be reassured of the normality of GOR (supported by Bliss parent information https://www.bliss.org.uk/parents/about-your-baby/medical-conditions/reflux)