• Many neurologically impaired children experience gastro-oesophageal reflux (15-75%)
• Consider reflux if child refuses food, vomits, has dysphagia, or is particularly irritable when lying flat. Also if there is unexplained weight loss, faltering growth failure, or respiratory symptoms such as recurrent respiratory tract infections, cough, wheeze or excessive respiratory secretions.

Management

General measures

• Exclude overfeeding
• If NG/ gastrostomy fed consider changing regimen from large bolus to more frequent small volumes
• Thicken feeds
• Check optimal posture for feeds
• Adjust posture overnight to keep child more upright: use blocks under cot/bed, or pillows.

Surgery can be considered in children with a longer prognosis. Fundoplication ± pyloroplasty is effective in 80%, but has a high rate of post-operative complications and recurrent symptoms are relatively common. Gastrostomy may also be an option.

Medication

Gaviscon

Form

Tablets: alginic acid 500mg, anhydrous aluminium hydroxide 100mg, magnesium trisilicate 25mg, sodium bicarbonate 170mg.
Liquid: sodium alginate 250mg, sodium bicarbonate 133.5mg, calcium carbonate 80mg in 5mL.
Infant sachets: sodium alginate 225mg, magnesium alginate 87.5mg with colloidal silical and mannitol / dose.

By mouth

Neonate–2 years, body weight < 4.5 kg: 1 dose (half dual sachet) when required mixed with feeds or with water for breast fed babies, maximum 6 doses in 24 hours,
Neonate–2 years body weight > 4.5 kg: 2 doses (1 dual sachet) when required mixed with feeds or with water for breast fed babies or older infants, maximum 6 doses in 24 hours,

Gaviscon Liquid

Child 2-12 years: 1 tablet or 5-10mL liquid after meals and at bedtime
Child 12-18 years: 1-2 tablets or 10-20mL after meals and at bedtime

Gaviscon Advance

Child 2-12 years: 1 tablet or 2.5-5mL after meals and at bedtime (under medical advice only)
Child 12-18 years: 1-2 tablets or 5-10mL suspension after meals and at bedtime

Licence: liquid and tablets licensed for use in children over 2yr, for children 2-6yr on medical advice only. Infant sachets licensed for infants and young children but for children under 1yr only under medical supervision.

Lansoprazole

Form

Tablet: 30mg
Capsule: 15mg
Orodispersable tablet (Fast tab): 15mg
Sachets (suspension): 30mg/sachet

Dose (oral)

Child body weight <30kg: 0.5-1mg/kg with maximum 15mg once daily in the morning
Child body weight>30kg: 15-30mg once daily in the morning

For administration via a NG or gastrostomy tube, lansoprazole FasTabs® can be dispersed in 10mL water and administered via an 8Fr NG tube without blockage. For smaller bore tubes, dissolve the contents of a lansoprazole capsule in 8.4% sodium bicarbonate before administration. If the tube becomes blocked, use sodium bicarbonate to dissolve any enteric coated granules lodged in the tube. Lansoprazole less likely than omeprazole MUPS to cause blockage of small bore tubes.

Licence: not licensed for use in children under 12 years of age but licensed in the US for use from 1 year of age.

Omeprazole

Form

Capsule: 10mg, 20mg, 40mg
MUPS dispersible tablets: 10mg, 20mg, 40mg
Tablets: 10mg, 20mg, 40mg
Intravenous infusion: 40mg vial
Intravenous injection: 40mg vial

Dose (oral)

Neonate: 700µg/kg once daily; increase if necessary to a maximum of 1.4mg/kg once daily (max dose: 2.8mg/kg once daily),
Child 1 month–2 years: 700µg/kg once daily; increase if necessary to a maximum of 3mg/kg once daily (max: 20mg once daily)
Child body weight 10–20 kg: 10mg once daily; increase if necessary to a maximum of 20mg once daily.
Child body weight > 20 kg: 20mg once daily; increase if necessary to a maximum of 40mg once daily.

Capsules can be opened and the granules mixed in acidic drink, e.g. orange juice.
Tablets can be dispersed in water or mixed with fruit juice or yogurt.

Contraindications and warnings: caution in patients with hepatic impairment.

Interactions: see appropriate text.

Licence: licensed for use in children >1yr with severe ulcerating reflux oesophagitis.

MUPS tablets can be dispersed in water, fruit juice or yogurt. Administer with care via enteral feeding tubes to minimise risk of blockage. Capsules may be opened and contents dispersed in 8.4% sodium bicarbonate for administration. Dispersible tablets disintegrate to give a dispersion of small granules. The granules settle quickly and may block fine-bore feeding tubes (less than 8Fr).

Ranitidine

Form

Tablet: 150mg, 300mg
Effervescent tablet: 150mg, 300mg
Syrup: 75mg in 5mL
Oral solution: 75mg in 5mL
Injection: 25mg in 1mL, 2mL ampoule

Dose (oral)

Neonate: 2–3mg/kg 3 times daily (absorption unreliable),
Child 1–6 months: 1 mg/kg 3 times daily increasing if necessary to maximum 3mg/kg 3 times daily,
Child 6 months–3 years: 2–4mg/kg twice a day,
Child 3–12 years: 2–4mg/kg (maximum single dose 150mg) twice a day. Dose may be increased up to 5mg/kg (maximum 300mg/dose) twice daily in severe gastro-oesophageal reflux disease,
Child 12–18 years: 150mg twice a day or 300mg at night. May be increased if necessary in moderate to severe gastro-oesophageal reflux disease to 300mg twice a day or 150mg 4 times daily for up to 12 weeks. By slow intravenous injection, diluted to 2.5mg/mL and given over at least 3 minutes (some adult centres give as subcutaneous injection (unlicensed route)):

Neonate: 0.5–1mg/kg every 6–8 hours (may need 2mg/kg 8 hourly as variable first pass metabolism affects uptake),
Child 1 month–18 years: 1mg/kg (max. 50mg) every 6–8 hours (may be given as an intermittent infusion at a rate of 25mg/hour).

Licence: Oral formulations not licensed for use in children < 3 years; injection not licensed for children under 6 months.

Domperidone

Domperidone is now contraindicated for use in those with underlying cardiac conditions and other risk factors.

The indications and doses below are therefore largely unlicensed usage in a particular population.

Form

Tablet: 10mg Suspension: 5mg in 5mL
Suppositories: 30mg

By mouth

Neonate: initial dose of 100µg/kg 4–6 times daily before feeds. Dose may be increased, if necessary, to maximum of 300µg/kg 4-6 times daily,
Child 1 month–12 years: initial dose of 200µg/kg (maximum single dose 10mg) 3-4 times daily before food. Dose may be increased, if necessary, to 400µg/kg 3-4 times daily. Maximum single dose 20 mg,
Child 12–18 years: initial dose of 10mg 3–4 times daily before food. Dose may be increased, if necessary, to 20mg 3-4 times daily.

Dose (rectal)

Body-weight 15–35 kg: 30mg twice a day,
Body-weight > 35 kg: 60mg twice a day.

Acute dystonic reactions less common than with metoclopramide. Licence: not licensed for gastro-oesophageal reflux in children.

Metoclopramide

To minimise the risk of neurological side effects associated with metoclopramide, the EMA in 2013 issued the following recommendations:
(NB use of metoclopramide in palliative care was excluded from these recommendations HOWEVER caution should be exercised nevertheless)

In children aged 1-18 years, metoclopramide should only be used as a second-line option for prevention of delayed chemotherapy-induced nausea and vomiting and for treatment of established postoperative nausea and vomiting.

Metoclopramide should only be prescribed for short term use (up to 5 days).

Form

Tablets: 5mg, 10mg

Syrup/oral solution: 5mg in 5mL Paediatric liquid: 1mg in 1mL Injection: 5mg in 1mL, 2mL ampoule.

Dose and routes

By mouth, IM injection, or IV injection (over at least 3 minutes):

Neonate: 100µg/kg every 6–8 hours (by mouth or IV only),
Child 1 month–1 year and body weight up to 10 kg: 100µg/kg (maximum. 1mg/dose) twice daily,
Child 1–18 years: 100-150µg/kg repeated up to 3 times daily. The maximum dose in 24 hours is 500µg/kg (maximum 10mg/dose).

Dystonic reactions which are reversible with benztropine or procyclidine can occur with any dose.
Cautions: in mild/moderate renal failure use 75% dose, in severe renal impairment use 25-50% dose. Reduce dose in severe liver disease.

Licence: not licensed for use in infants <1yr, tablets licensed only in children >15yr.

Erythromycin

Form

Tablets and liquid.

Dose

Neonate: 3mg/kg 4 times daily,
Child 1 month–18 years: 3mg/kg 4 times daily.