Gastro-oesophageal reflux disease in children and young people: diagnosis and management

National Institute for Health and Care Excellence


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Diagnosing and investigating GORD

  • Recognise regurgitation of feeds as a common and normal occurrence in infants that:
    • is due to gastro-oesophageal reflux (GOR)—a normal physiological process in infancy
    • does not usually need any investigation or treatment
    • is managed by advising and reassuring parents and carers
  • Be aware that in a small proportion of infants, GOR may be associated with:
    • signs of distress or may lead to certain recognised complications that need clinical management. This is known as gastro-oesophageal reflux disease (GORD)
  • Give advice about GOR and reassure parents and carers that in well infants, effortless regurgitation of feeds:
    • is very common (it affects at least 40% of infants)
    • usually begins before the infant is 8 weeks old
    • may be frequent (5% of those affected have 6 or more episodes each day)
    • usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year old)
    • does not usually need further investigation or treatment
  • When reassuring parents and carers about regurgitation, advise them that they should return for review if any of the following occur:
    • the regurgitation becomes persistently projectile
    • there is bile-stained (green or yellow-green) vomiting or haematemesis (blood in vomit)
    • there are new concerns, such as signs of marked distress, feeding difficulties or faltering growth
    • there is persistent, frequent regurgitation beyond the first year of life
  • In infants, children and young people with vomiting or regurgitation, look out for the ‘red flags’ in table 1, which may suggest disorders other than GOR. Investigate or refer using clinical judgement
  • Do not routinely investigate or treat for GOR if an infant or child without overt regurgitation presents with only 1 of the following:
    • unexplained feeding difficulties (for example, refusing to feed, gagging or choking)
    • distressed behaviour
    • faltering growth
    • chronic cough
    • hoarseness
    • a single episode of pneumonia
  • Consider referring infants and children with persistent back arching or features of Sandifer’s syndrome (episodic torticollis with neck extension and rotation) for specialist assessment
  • Recognise the following as possible complications of GOR in infants, children and young people:
    • reflux oesophagitis
    • recurrent aspiration pneumonia
    • frequent otitis media (for example, more than 3 episodes in 6 months)
    • dental erosion in a child or young person with a neurodisability, in particular cerebral palsy
  • Recognise the following as possible symptoms of GOR in children and young people:
    • heartburn
    • retrosternal pain
    • epigastric pain
  • Be aware that GOR is more common in children and young people with asthma, but it has not been shown to cause or worsen it
  • Be aware that some symptoms of a non-IgE-mediated cows’ milk protein allergy can be similar to the symptoms of GORD, especially in infants with atopic symptoms, signs and/or a family history. If a non-IgE-mediated cows’ milk protein allergy is suspected, see the NICE guideline on food allergy in children and young people
  • When deciding whether to investigate or treat, take into account that the following are associated with an increased prevalence of GORD:
    • premature birth
    • parental history of heartburn or acid regurgitation
    • obesity
    • hiatus hernia
    • history of congenital diaphragmatic hernia (repaired)
    • history of congenital oesophageal atresia (repaired)
    • a neurodisability
  • GOR only rarely causes episodes of apnoea or apparent life-threatening events (ALTEs), but consider referral for specialist investigations if it is suspected as a possible factor following a general paediatric assessment
  • For children and young people who are obese and have heartburn or acid regurgitation, advise them and their parents or carers (as appropriate) that losing weight may improve their symptoms (also see the NICE guideline on obesity)
  • Arrange an urgent specialist hospital assessment to take place on the same day for infants younger than 2 months with progressively worsening or forceful vomiting of feeds, to assess them for possible hypertrophic pyloric stenosis
  • Arrange a specialist hospital assessment for infants, children and young people for a possible upper GI endoscopy with biopsies if there is:
    • haematemesis (blood-stained vomit) not caused by swallowed blood (assessment to take place on the same day if clinically indicated; also see table 1)
    • melaena (black, foul-smelling stool; assessment to take place on the same day if clinically indicated; also see table 1)
    • dysphagia (assessment to take place on the same day if clinically indicated)
    • no improvement in regurgitation after 1 year old
    • persistent, faltering growth associated with overt regurgitation
    • unexplained distress in children and young people with communication difficulties
    • retrosternal, epigastric or upper abdominal pain that needs ongoing medical therapy or is refractory to medical therapy
    • feeding aversion and a history of regurgitation
    • unexplained iron-deficiency anaemia
    • a suspected diagnosis of Sandifer’s syndrome
  • Investigate the possibility of a urinary tract infection in infants with regurgitation if there is:
    • faltering growth
    • late onset (after the infant is 8 weeks old)
    • frequent regurgitation and marked distress
Table 1 ‘Red flag’ symptoms suggesting disorders other than GOR
Symptoms and signs Possible diagnostic implications Suggested actions
Gastrointestinal
Frequent, forceful (projectile) vomiting May suggest hypertrophic pyloric stenosis in infants up to 2 months old Paediatric surgery referral
Bile-stained (green or yellow-green) vomit May suggest intestinal obstruction Paediatric surgery referral
Haematemesis (blood in vomit) with the exception of swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast-fed infants May suggest an important and potentially serious bleed from the oesophagus, stomach or upper gut Specialist referral
Onset of regurgitation and/or vomiting after 6 months old or persisting after 1 year old Late onset suggests a cause other than reflux, for example a urinary tract infection (also see the NICE guideline on urinary tract infection in children)
Persistence suggests an alternative diagnosis
Urine microbiology investigation Specialist referral
Blood in stool May suggest a variety of conditions, including bacterial gastroenteritis, infant cows’ milk protein allergy (also see the NICE guideline on food allergy in children and young people) or an acute surgical condition Stool microbiology investigation
Specialist referral
Abdominal distension, tenderness or palpable mass May suggest intestinal obstruction or another acute surgical condition Paediatric surgery referral
Chronic diarrhoea May suggest cows' milk protein allergy (also see the NICE guideline on food allergy in children and young people) Specialist referral
Systemic
Appearing unwell
Fever
May suggest infection (also see the NICE guideline on feverish illness in children) Clinical assessment and urine microbiology investigation
Specialist referral
Dysuria May suggest urinary tract infection (also see the NICE guideline on urinary tract infection in children) Clinical assessment and urine microbiology investigation
Specialist referral
Bulging fontanelle May suggest raised intracranial pressure, for example, due to meningitis (also see the NICE guideline on bacterial meningitis and meningococcal septicaemia) Specialist referral
Rapidly increasing head circumference (more than 1 cm per week)
Persistence morning headache, and vomiting worse in the morning
May suggest raised intracranial pressure, for example, due to hydrocephalus or a brain tumour Specialist referral
Altered responsiveness, for example, lethargy, or irriablility May suggest an illness such as meningitis (also see the NICE guideline on bacterial meningitis and meningococcal septicaemia) Specialist referral
Infants and children with, or at high risk of, atopy May suggest cows' milk protein allergy (also see the NICE guideline on food allergy in children and young people) Specialist referral

Initial management of GOR and GORD

  • Do not use positional management to treat GOR in sleeping infants. In line with NHS advice, infants should be placed on their back when sleeping
  • In breast-fed infants with frequent regurgitation associated with marked distress, ensure that a person with appropriate expertise and training carries out a breastfeeding assessment
  • In formula-fed infants with frequent regurgitation associated with marked distress, use the following stepped-care approach:
    • review the feeding history, then
    • reduce the feed volumes only if excessive for the infant’s weight, then
    • offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent, then
    • offer a trial of thickened formula (forexample, containing rice starch, cornstarch, locust bean gum or carob bean gum)
  • In breast-fed infants with frequent regurgitation associated with marked distress that continues despite a breastfeeding assessment and advice, consider alginate therapy for a trial period of 1–2 weeks. If the alginate therapy is successful continue with it, but try stopping it at intervals to see if the infant has recovered
  • In formula-fed infants, if the stepped-care approach is unsuccessful, stop the thickened formula and offer alginate therapy for a trial period of 1–2 weeks. If the alginate therapy is successful continue with it, but try stopping it at intervals to see if the infant has recovered

Pharmacological treatment of GORD

  • Do not offer acid-suppressing drugs, such as proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs), to treat overt regurgitation in infants and children occurring as an isolated symptom
  • Consider a 4-week trial of a PPI or H2RA for those who are unable to tell you about their symptoms (for example, infants and young children, and those with a neurodisability associated with expressive communication difficulties) who have overt regurgitation with 1 or more of the following:
    • unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
    • distressed behaviour
    • faltering growth
  • Consider a 4-week trial of a PPI or H2RA for children and young people with persistent heartburn, retrosternal or epigastric pain
  • Assess the response to the 4-week trial of the PPI or H2RA, and consider referral to a specialist for possible endoscopy if the symptoms:
    • do not resolve or
    • recur after stopping the treatment
  • When choosing between PPIs and H2RAs, take into account:
    • the availability of age-appropriate preparations
    • the preference of the parent (or carer), child or young person (as appropriate)
    • local procurement costs
  • Offer PPI or H2RA treatment to infants, children and young people with endoscopy-proven reflux oesophagitis, and consider repeat endoscopic examinations as necessary to guide subsequent treatment
  • Do not offer metoclopramide, domperidone or erythromycin to treat GOR or GORD without seeking specialist advice and taking into account their potential to cause adverse events

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/NG1

National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. January 2015.


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