The scenarios are fictitious but similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could be also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.
The following case studies written by Dr Jennifer Parkhouse relate to her expert article, Top tips: GORD in infants, children, and young people. In her article, Dr Parkhouse explores some essential points to consider when suspecting gastro-oesophageal reflux disease (GORD) in infants, children, and young people.
Case 1: Rufus, 6 Weeks Old
Rufus was born at term with no complications. He is a bottle-fed baby. He was last weighed at 4 weeks of age and his mother says the health visitor said everything was fine. His mother is concerned that he brings up a lot of his feeds and is concerned that he is not getting enough milk. She feels there must be something wrong as her older daughter was never sick this much and doesn’t think it is normal.
Questions for Reflection
- What further information do you need?
- What examination would you like to do?
- What are you going to say to the mother?
How to Manage This PatientIt is important to clarify what amount of milk Rufus is getting and to calculate whether he might be overfed. Most formula fed infants from the first week to 6 months of age will need a total feed volume over 24 hours of 150 ml/kg body weight. It is important to check the red book and ensure that he is gaining weight appropriately. Rufus should be fully examined, particularly including abdominal, respiratory, head, and neurological examinations.
The mother should be reassured that Rufus has gastro-oesophageal reflux (GOR) and that it is very common in babies. It does not require treatment unless the baby is showing signs of distress. He is gaining weight and therefore is getting the amount of feed that he requires.
Case 2: Amelie, 11 Weeks Old
Amelie has had several GP appointments recently. She has attended regarding problems with gastro-oesphageal reflux disease (GORD). She was bringing up lots of her feeds and appeared distressed when feeding. She is breast- and formula-fed. She was started on sodium alginate, which helped a bit, but she has continued to be very unhappy. She was then given some omeprazole and although this helped slightly, with her being happier taking her feeds, she has continued to be very unhappy most of the time. She had a generalised rash when seen previously and has been given creams for this. Her mother mentions that her bowels can be quite explosive.
Questions for Reflection
- What are the possible diagnoses?
- What other questions might you ask to help with the diagnosis?
- How would you manage this?
- What advice would you give the mother?
How to Manage This PatientThe possible diagnoses are that she has GORD and that it is not responding to treatment or that she has non-IgE-mediated cow’s milk allergy (CMA). Non-IgE-mediated CMA can present in a very similar way to GORD and it can be difficult to distinguish between the two. Asking further detailed questions about other associated symptoms is important. The skin as well as the gastrointestinal and respiratory systems are most commonly affected, so clarifying information about the rash and bowel symptoms is important. As Amelie is on medication it is also important to clarify the dose she is taking, as the dose of omeprazole might not be in a therapeutic range if she has gained weight and the medication has not been adjusted accordingly.
With a combination of GORD, rash, bowel symptoms, and an unhappy baby this is more likely a case of non-immunoglobulin E (IgE)-mediated CMA. You would advise the mother that cow’s milk protein needs to be removed from Amelie’s diet. For Amelie, this involves using a hypoallergenic milk formula, and for the mother it will mean excluding cow’s milk protein from her own diet. This should be trialled for 2–6 weeks to see if the symptoms improve and then cow’s milk protein should be reintroduced to see the response.
It is very important that the mother has adequate calcium and vitamin D replacements.
Case 3: Evan, 6 Weeks Old
Evan is a first child. He has been vomiting up feeds from around 4 weeks of age. His mother thought it was probably the formula he didn’t like and so has tried various different formulas. He has recently been weighed and he has not gained any weight and has dropped a centile. He is fully bottle feeding and always seems to be hungry. The vomiting has got worse and seems to be more forceful and for the past 24 hours he has had fewer wet nappies.
Questions for Reflection
- What is the most likely diagnosis?
- What examination might help in the diagnosis?
- How might you approach managing this baby?
How to Manage This Patient
The most likely diagnosis here is pyloric stenosis. This a condition that affects babies between 2 and 10 weeks of age. Pyloric stenosis is a narrowing of the pylorus (passage between the stomach and small intestine) and this narrowing obstructs the movement of milk or food into the intestine, resulting in progressively worsening and more forceful vomiting.
An olive shaped mass may be palpable in the right upper abdomen and is best palpated at the start of a feed.
Evan should be admitted to hospital that day for further investigations and management.