Drs Tom McAnea (pictured) and John Martin summarise the key priorities for implementation in recent NICE guidance on the care of infants, children, and young people with gastro-oesophageal reflux disease

mcanea tom

Independent content logo

Read this article to learn more about:

  • how to assess and diagnose infants and children who may have GOR/GORD
  • red-flag symptoms that require urgent referral
  • stepwise management and treatment for children with GOR/GORD.

Key points

GP commissioning messages

NICE Accreditation Mark
NICE Accreditation Mark

 

NICE Guideline 1 on Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people has been awarded the NICE Accreditation Mark.

This Mark identifies the most robustly produced guidance available.
See evidence.nhs.uk/accreditation for further details.

 

Gastro-oesophageal reflux (GOR) is common in infants, but also presents in children and young people. It affects up to 40% of infants, usually beginning before 8 weeks of age, and is likely to resolve completely by age 1 year in 90% of those infants affected.1 In well infants with effortless regurgitation, it is important to reassure parents that this requires no investigation or treatment other than advice and support.1

Discussing the symptoms and potential duration of GOR at the outset will help to reassure parents; it is important to stress that the symptoms will improve and resolve without any treatment or other intervention in the majority of cases.1

When reassuring parents, however, it is important to advise them to return with their child for review if any red-flag symptoms occur (see section on 'Red flags' below and in the Guidelines  summary on GORD.1

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) occurs when the effect of GOR leads to symptoms that are severe enough to warrant medical advice.1 This article presents an overview of the recommended approach in assessing, treating, and managing GOR or GORD, with particular reference to NICE Guideline (NG) 1 on Gastrooesophageal reflux disease: recognition, diagnosis and management in children and young people1 published in January 2015. The recommendations in the guideline cover children from birth up to the age of 18 years.

Click here to view the NICE pathway for dyspepsia and GORD.

Assessment and diagnosis

A thorough and careful history is the mainstay of diagnosis and assessment of GOR and GORD in primary care. Most children affected will not require investigation or referral to secondary care but can be safely and effectively managed within the community (e.g. by GPs, nurses, health visitors, and breastfeeding advisors).1

History and examination

If GORD is suspected, then take a feeding history and ensure a feeding assessment has been carried out by an appropriately skilled and trained health professional such as a midwife, health visitor, or breastfeeding support nurse.1 In bottle-fed children, ask about the formula used, for example, preparation, volume and frequency of feeds, and any resistance or refusal to feed, in order to establish whether a 'normal' or GOR specific formula is used, as resistance or refusal to feed with the former may suggest discomfort or pain associated with reflux. In breast-fed infants, advice should be given to the mother about technique, positioning, and attachment.

Establish when the symptoms started, and ask about frequency of vomiting episodes, distress, any respiratory symptoms, and any instances of backarching or apnoeic episodes. In a small proportion of infants, there may be signs of distressed behaviour (e.g. excessive crying, crying and/or arching of the back while feeding) associated with symptoms of GOR (regurgitation), which may lead to certain complications requiring management.1

Physical examination should focus on general appearance and wellbeing, and the chest and abdomen.

Other symptoms to be aware of in a suspected diagnosis of GORD, are:1

  • unexplained feeding difficulties (e.g. refusing to feed, gagging, or choking)
  • chronic cough or hoarseness
  • a single episode of pneumonia
  • faltering growth.

However, in an infant presenting with only one of these symptoms, in the absence of overt regurgitation, they should not be routinely investigated or treated for GORD. Faltering growth in an infant could be due to GORD, however first-line investigations in this instance should not be directed at a diagnosis of GORD, rather considering other potential diagnoses.

In children aged over 1 year, GORD may present with heartburn, retrosternal and epigastric pain, whereas in children aged under 1 year GORD may present with evidence of distress, either during or after eating; possibly regular vomiting after eating, or regurgitation of food.

'Red flags'

In children with regurgitation, there may be red-flag symptoms that are important to recognise (see Table 1 in the Guidelines summary on GORD); these symptoms suggest disorders other than GOR and will require referral for further investigation and management.

Arrange a specialist hospital assessment for infants, children, and young people for a possible upper gastrointestinal endoscopy with biopsies if there is:1

  • haematemesis (blood-stained vomit) not caused by swallowed blood (assessment to take place on the same day if clinically indicated;
  • melaena (black, foul‑smelling stool; assessment to take place on the same day if clinically indicated;
  • 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 with a history of regurgitation
  • unexplained iron deficiency anaemia
  • suspected diagnosis of Sandifer's syndrome.

Risk factors for GORD

There are some risk factors associated with an increased risk of GORD, which GPs should consider when contemplating, investigating, or treating children with suspected GORD:1

  • premature birth
  • parental history of heartburn or acid regurgitation
  • obesity
  • hiatus hernia
  • history of congenital diaphragmatic hernia that has been repaired
  • congenital oesophageal atresia that has been repaired
  • a neurodisability.

Initial management of GOR and GORD

Positional management for sleeping infants

Infants should always be put to sleep on their back, irrespective of symptoms that may suggest GOR/GORD.

Breast-fed infants

In breast-fed infants with frequent regurgitation associated with marked distress, carry out a breastfeeding assessment. This can be done by any suitably qualified person in the community.1

If the regurgitation with marked distress continues despite the breastfeeding advice, offer a 1–2 week trial of alginate therapy. If this is successful, continue with it but consider periodically stopping the treatment to assess symptoms and see if the infant has recovered.1

Formula-fed infants

In formula-fed infants with overt regurgitation associated with marked distress, consider the following stepwise approach:1

  • review the feeding history, then
  • reduce feed volumes only if excessive for the infant's weight,2 then
  • suggest a trial of smaller, more frequent feeds, equalling an appropriate total intake over 24 hours:
    • if the feeds are already small and frequent then suggest a trial of thickener (e.g. containing rice starch, cornstarch, locust bean gum, or carob bean gum).

If the above approach is ineffective, then stop the thickeners and offer a trial of alginate therapy for 2 weeks. If this is effective, then continue with it but consider periodically stopping to see if symptoms have improved.1

Pharmacological treatment of GORD

Exercise clinical judgement when deciding how long initial treatments should be trialled before pharmacological treatments are considered. Usually around 2–4 weeks is sufficient, although ultimately this is dependent on individual circumstances and should be discussed with the parent.

NICE NG1 includes the following recommendations for practitioners considering pharmacological treatment for infants, children, and young people with GORD: 1

  • do not offer:
    • to prescribe proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) to infants with overt regurgitation as an isolated symptom
    • metoclopramide, domperidone, or erythromycin to treat GOR or GORD without seeking specialist advice and take into account their potential to cause adverse events3,4
  • consider a 4-week trial of a PPI or H2 RA for:
    • children unable to tell you about their symptoms (e.g. infants and young children, and those with a neurodisability associated with expressive communication difficulties), who have overt regurgitation with at least one of the following:
      • distressed behaviour
      • unexplained feeding difficulties (e.g. refusing feeds, gagging, or choking)
      • faltering growth
    • children and young people with persistent heartburn, retrosternal or epigastric pain:
      • assess response to a PPI or H2 RA after the 4-week trial and consider referral to a specialist if the symptoms do not resolve, or recur after stopping treatment
  • when choosing between PPIs and H2 RAs, consider:
    • the availability of age-appropriate preparations
    • the preference of the parent and their child
    • local prescribing advice.

The role of primary care

The GP and primary care team have a key role to play in managing infants and children presenting with GOR/GORD. There are potential challenges in terms of follow-up appointments, pressure to prescribe medication, and ensuring continuity of care; however, primary care is the most appropriate setting for offering care and advice to the vast majority of the parents, infants, and children presenting with these conditions.

Opportunities may already exist in practices for sharing best practice; for example in baby clinics run by GPs and health visitors, auditing prescribing of drugs in these cases, and reflecting upon current practice in light of the guidelines.

Further information

A range of resources for parents, carers and healthcare professionals are available; see Box 1, below for more information.

Box 1: Sources of advice and support1

UK based charities that can offer advice and support to parents and carers include:

Bliss

  • Works to ensure that all babies in the UK born prematurely or sick receive the highest possible standard of care:

Living with Reflux

National Childbirth Trust (NCT)

  • Set up to provide help and support to parents with accurate and impartial information:

Conclusion

Gastro-oesophageal reflux is common in infants and can be effectively managed by GPs and other primary care healthcare professionals offering advice and reassurance to parents. Gastro-oesophageal reflux disease occurs in a small proportion of this group and typically presents as marked distress in the presence of overt regurgitation. This can also be effectively managed in primary care in the majority of cases, bearing in mind the usual caveats regarding red flags and other possible diagnoses (see Table 1 of Guidelines).

There are opportunities to share advice and best practice within the team (e.g. in joint baby clinics, multidisciplinary team meetings, and in auditing prescribing of drugs).

NICE Guideline 11 sets out a clear step-wise approach to managing these infants, children, and young people without the need for specialist investigation or referral in the vast majority of cases. Approaches to managing this condition vary greatly, due local variations in experience and expertise, as well as differences in local referral criteria. In view of this, the new guideline offers much-needed and welcome clarification for GPs regarding best practice in this area.

Key points

  • Gastro-oesophageal reflux (GOR) in infants is common, affecting approximately 40% or more of babies aged under 1 year
  • Simple gastro-oesophageal reflux requires no treatment other than advice and reassurance
  • Be aware of 'red flags' and refer children appropriately
  • Gastro-oesophageal reflux disease (GORD) is regurgitation in the presence of significant distress, feeding difficulties, or faltering growth
  • Chronic cough or hoarseness, or a single episode of pneumonia in the presence of regurgitation, should raise the possibility of a diagnosis of GORD
  • In breast-fed infants with frequent regurgitation associated with marked distress, carry out a breastfeeding assessment:
    • if this is ineffective, consider a 2-week trial of alginate
  • In formula-fed infants with overt regurgitation associated with marked distress, suggest reducing feed volumes and trial more frequent feeds:
    • if the feeds are already small and frequent, then suggest a trial of thickener
    • if smaller, frequent feeds and thickener are ineffective, then consider a 2-week trial of alginate
  • Do not offer to prescribe PPIs or H2RAs to infants with overt regurgitation as an isolated symptom
  • Do not offer metoclopramide, domperidone, or erythromycin to treat GOR or GORD without seeking specialist advice.

PPI=proton pump inhibitor; H2RA=H2 receptor antagonist

Back to top

CP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • GORD is a common but mostly benign condition that can usually be effectively managed in primary care
  • CCGs working with specialist and community children's services should agree and publish local care pathways for this condition based on NICE Guideline 1
  • These local guidelines should give simple clear instructions for local health visitors and GPs, and could include information leaflets for the families and carers of affected children
  • Triggers for referral and red-flag symptoms should be identified with guides as to which service should be involved (e.g. consultant paediatrician or paediatric dietetic services)
  • Local CCG formularies should identify alginates and thickeners for use with the appropriate dosing and quantities for children of different ages and also identify which drugs should be reserved for specialist use
  • Tariff costs for paediatric gastroenterology: £254 (new); £148 (follow up).a

www.england.nhs.uk/resources/pay-syst/tariff-guide/

GORD=gastro-oesophageal reflux disease; CCG=clinical commissioning group

Back to top

References

  1. NICE. Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people. NICE Guideline 1. NICE, 2015. Available at: www.nice.org.uk/ guidance/ng1
  2. Great Ormond Street Hospital for Children.Infant feeding: formula. 2014. Available at:www.gosh.nhs.uk/health-professionals/ clinical-guidelines/infant-feedingformula# Rationale….. 150mls/Kg/day (accessed 2 June 2015)
  3. European Medicines Agency. European Medicines Agency recommends changes to the use of metoclopramide. EMA, 2013. Available at: www.ema.europa.eu/docs/en_GB/ document_library/Press_release/2013/07/ WC500146614.pdf (accessed 5 June 2015)
  4. European Medicines Agency. CMDh confirms recommendations on restricting use of domperidone-containing medicines. EMA, 2014. http://www.ema.europa.eu/ docs/en_GB/document_library/Press_ release/2014/04/WC500165651.pdf (accessed 5 June 2015)