Neonatal gastro-oesophageal reflux and aspiration — structured oral (viva)

Branching structured oral on a preterm infant with posseting and feed-related desaturations, testing the distinction between physiologic reflux and disease, conservative-first management, and the evidence on acid suppression and the reflux-apnoea link.

branching clinical structured oral2 min readVerification in progress

Prompt

A 32-week preterm infant, now 3 weeks old and growing along the 9th centile, has frequent effortless posseting after bolus tube feeds and occasional desaturation to 88 percent in the hour after feeds. The nurses ask you to start a proton-pump inhibitor for reflux. There are no red flags on examination.

Branch 1 — Definition and classification

Examiner: "Is this reflux or GORD, and what separates the two?" Candidate: This is physiologic gastro-oesophageal reflux. GOR is the effortless retrograde passage of gastric contents into the oesophagus, and in the neonate it is almost always physiologic and self-limiting. GORD is reserved for reflux that causes complications — failure to thrive, haematemesis, oesophagitis, recurrent aspiration, or distress. This infant is thriving on the 9th centile with effortless posseting and no red flags, so this is physiologic reflux, not disease. [1]

Examiner: "What red flags would change your mind?" Candidate: I would reconsider if there were bilious or green vomiting, forceful or projectile vomiting, faltering growth, visible blood in the vomit or anaemia, persistent irritability or arching, or recurrent aspiration. Bilious vomiting is the cardinal danger sign — it signals intestinal obstruction, most dangerously malrotation with volvulus, and it needs urgent contrast imaging and surgical review, not anti-reflux therapy. [1]

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References3Show ledger

[1]Rosen R, Vandenplas Y, Singendonk M, et al Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr, 2018.PMID 29470322
[2]Tighe MP, Andrews E, Liddicoat I, et al. Pharmacological treatment of gastro-oesophageal reflux in children. Cochrane Database Syst Rev, 2023.PMID 37635269
[3]Poets CF Gastroesophageal reflux and apnea of prematurity—coincidence, not causation. Neonatology, 2013.PMID 23172077