Dr Jennifer Parkhouse offers 10 top tips on identifying and managing gastro-oesophageal reflux disease in children

parkhouse jennifer

Dr Jennifer Parkhouse

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Read this article to learn more about:

  • distinguishing normal from abnormal symptoms
  • ‘red flag’ symptoms, alternative diagnoses, and when to refer
  • stepwise management of infants and when to offer medications.

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Gastro-oesophageal reflux (GOR) is the passage of stomach contents into the oesophagus with or without accompanied regurgitation and vomiting. GOR is a normal physiological process that occurs throughout the day in infants and less often in older children.1

Gastro-oesophageal reflux disease (GORD) is GOR that causes symptoms, such as discomfort or pain, which become severe enough to merit treatment, or complications such as oesophagitis or pulmonary aspiration that require further management.2,3

1. Know what is normal

GOR is very common, with at least 40% of infants (children under 1 year) affected. It usually presents under the age of 8 weeks and can be frequent. This frequency generally reduces with time and does not usually require investigation or treatment.2,3 Regurgitation most commonly reflects physiological immaturity of the gastro-oesophageal junction, including a short distance and the lack of acute angle between the oesophagus and gastric fundus where the food is stored initially after ingestion.4 Frequent large-volume feeds and supine positioning predispose infants to regurgitation or vomiting induced by transient lower oesophageal sphincter relaxation. This relaxation continues into childhood, but when the child grows and becomes more upright, it happens less frequently.1

GOR symptoms remain common in childhood, with 2–7% of parents reporting symptoms in their children aged 3–9 years, such as epigastric discomfort or reflux. Some of these children may have GORD and need treatment.5

GORD is much less common with an estimated incidence of 1.48 cases per 1000 person-years in infants.1

Table 1 shows the features that distinguish GOR from GORD.

Table 1: Clinical features that distinguish GOR from GORD in infants and children1
Body systemGOR featuresGORD featuresSigns and symptoms requiring further evaluation

Vital signs and growth parameters

Normal weight gain

  • Poor weight gain or weight loss, failure to thrive

  • Fever

  • Failure to thrive

 

Gastro-intestinal

Little difficulty with feedings

Symptoms are not bothersome to the infant or child

  • Feeding refusal or prolonged feedings

  • Postprandial irritability in infants

  • Dysphagia or odynophagia

  • Recurrent vomiting

  • Heartburn in children

  • Chest pain, epigastric pain, non-localised abdominal pain

  • Regurgitation and/or vomiting beyond 18 months of age

 

  • Bilious vomiting

  • Persistent, forceful vomiting

  • Onset of vomiting after 6 months of age

  • Gastrointestinal bleeding

  • Persistent diarrhoea or constipation

  • Abdominal tenderness or distension, hepatosplenomegaly

Respiratory

No significant symptoms

  • Chronic cough, wheezing, or hoarseness

  • Asthma

  • Recurrent laryngitis, pneumonia, sinusitis, or otitis media

  • Apnoea or cyanosis (i.e., apparent life-threatening event)

 

  • Apnoea or cyanosis (i.e., apparent life-threatening event)

Nervous system

No neurobehavioural symptoms

  • Sandifer syndrome (neck tilting in infants)

  • Sandifer syndrome

  • Lethargy

  • Bulging fontanelle

  • Micro- or macrocephaly

  • Seizures

  • Neurodevelopmental delay or other disorders

 

GOR=gastro-oesophageal reflux; GORD=gastro-oesophageal reflux disease

Baird D, Harker D, Karmes A. Diagnosis and treatment of gastro-oesphageal reflux in infants and children. Am Fam Physician 2015; 92 (8): 705–714.

Reproduced with permission.

2. Be alert to GORD risk factors

Some children are at higher risk of developing GORD. The following are associated with an increased prevalence of GORD:3

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

3. Check the child’s ‘red book’ and examine them thoroughly

The diagnosis of GOR and GORD is made mainly from the history and examination. The diagnosis of GOR is by definition the presence of non-troublesome reflux. The diagnosis of GORD is usually based on the parent reporting symptoms that are attributable to GOR and are troublesome to the child.1

Gastro-oesophageal reflux in infants may present with frequent vomiting or regurgitation, prolonged feeding, feeding refusal, back-arching, or irritability after feeds.1 As with adults, older children and adolescents may report symptoms that include heartburn, epigastric pain, anorexia, or dysphagia. Children over the age of 8 years are considered to be reliable in their history.1

If the child is breast-fed, advice should be given to the mother with regard to breastfeeding technique, positioning, and attachment. In formula-fed infants, a thorough feeding history should be taken to exclude problems like overfeeding, which might be contributing to the problem. Most formula-fed infants from the first week to 6 months of age will need a total feed volume of 150 ml/kg body weight in 24 hours (6–8 times a day).6

A thorough systems examination is required to exclude any other possible diagnoses. This should also include growth measurements.1 All children from birth to the age of 4 years have a ‘red book’, which may include vital pieces of information, for example, if the child has been having regular weight-checks it will highlight any weight concerns that might then require further action.

An abdominal examination should be performed looking for tenderness, hepatosplenomegaly, palpable masses, distension, and peritoneal tenderness. The lungs should be examined to look for stridor and wheezing. The head and neurological examination should look for micro/macrocephaly, bulging fontanelle, and signs of any neurodevelopmental disorder.1

4. Consider alternative diagnoses and know the ‘red flags’

In infants and children with vomiting it is important to consider other diagnoses. Table 2 documents other possible conditions that could present in a similar way to GOR or GORD and their distinguishing features.2,3

Table 2: ‘Red flag’ symptoms suggesting disorders other than gastro-oesophageal reflux3
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 under 16s [Clinical Guideline 54])

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 under 19s [Clinical Guideline 116]) 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 under 19s [Clinical Guideline 116])

Specialist referral

Systemic

Appearing unwell

Fever

May suggest infection (also see the NICE guideline on fever in under 5s [Guideline 143])

Clinical assessment and urine microbiology investigation

Specialist referral

Dysuria

May suggest urinary tract infection (also see the NICE guideline on urinary tract infection in under 16s [Clinical Guideline 54])

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 meningitis (bacterial) and meningococcal septicaemia in under 16s [Clinical Guideline 102])

Specialist referral

Rapidly increasing head circumference (more than 1 cm per week)

Persistent 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 irritability

May suggest an illness such as meningitis (also see the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s [Clinical Guideline 102])

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 under 19s [Clinical Guideline 116])

Specialist referral

© NICE 2019. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. Available from: www.nice.org.uk/guidance/ng1 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Non-IgE-mediated cows’ milk allergy can present in a very similar way to GORD and it can be difficult to distinguish between the two. Think of non-IgE-mediated cows’ milk allergy if the child presents with GORD symptoms and also symptoms that affect other systems.3,7 Such symptoms can include:7

  • skin: pruritus, erythema, and atopic eczema
  • gastrointestinal: GORD, loose or frequent stools, blood and/or mucous in stools, abdominal pain, infantile colic, food refusal or aversion, constipation, perianal redness, pallor and tiredness, faltering growth with at least one or more of the gastrointestinal symptoms (with or without significant atopic eczema)
  • respiratory: lower respiratory tract symptoms (such as cough, chest tightness, wheezing, or shortness of breath).

If non-IgE-mediated cows’ milk allergy is suspected, then NICE guidance for its management should be followed. This involves a trial elimination of cows’ milk from the diet for 2–6 weeks followed by reintroduction of cows’ milk to demonstrate whether this is the cause of the symptoms. For breast-fed babies, the mother needs to exclude cows’ milk protein from her diet (ensuring she has adequate vitamin D and calcium replacements). Bottle-fed babies should have the cows’ milk formula replaced with a hypoallergenic milk formula.7

5. Remember that medications are not always required

Most infants and children with reflux will improve with conservative management. Parents of healthy infants should be reassured that most spontaneous regurgitation resolves in the first year of life.1

A literature review published in 2018 concluded that, by providing parents with full and updated education, reassurance, and nutritional advice, healthcare professionals can optimise management of functional gastrointestinal disorders and associated symptoms and reduce inappropriate use of medication and dietary interventions.8

Initial management of GOR and GORD

Positional management to treat GOR in sleeping infants should not be used; this is to ensure that parents adhere to NHS advice to place children on their backs to reduce the incidence of sudden infant death syndrome (SIDS).3,9

NICE guidance gives a clear, stepwise approach to the management of GORD.2,3

Breast-fed infants with frequent regurgitation associated with marked distress should have their feeding assessed by a breastfeeding specialist.

In formula-fed infants with frequent regurgitation and marked distress, the following stepwise approach is suggested:3

  • review the 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 a thickened formula (for example, 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 this therapy is successful continue it, stopping at intervals to see if it is still required.3

In formula-fed infants, if the stepwise approach is not helpful, offer alginate therapy for a trial period of 1–2 weeks. As with breast-fed babies, try stopping it at intervals to see if it is still required.3

6. Know when, and when not, to offer medication

NICE guidance states that acid suppressing drugs such as H2 receptor antagonists (H2 RAs) or proton pump inhibitors (PPIs) should not be offered to infants and children with overt regurgitation occurring as an isolated symptom.2,3

Consider a 4-week trial of a PPI or H2 RA in children who do not respond to non-pharmacological measures, are unable to tell you about their symptoms, and have overt regurgitation with one or more of the following:3

  • unexplained feeding difficulties such as refusing feeds, gagging, or choking
  • distressed behaviour
  • faltering growth.

It should be noted that not all PPIs and H2 RAs are licensed for use in children and those that are licensed can vary in the age that they are licensed from. For licensing and prescribing information, refer to the individual summary of product characteristics (SPCs) and the British National Formulary (BNF) for children. MHRA drug safety updates have been issued for PPIs, covering hypomagnesaemia, increased risk of fracture with long-term use, and very low risk of subacute cutaneous lupus erythematosus.3

There are currently (March 2020) issues with the availability of ranitidine,10 which is often the first choice of medication. Check with your local hospital for their suggested first-line medication(s) if it was previously ranitidine.

Do not offer metoclopramide, erythromycin, or domperidone to treat GOR or GORD unless all of the following conditions are met:2,3

  • the potential benefits outweigh the risks of adverse effects
  • other interventions have been tried
  • there is specialist paediatric professional agreement for its use.

Note that metoclopramide, domperidone, and erythromycin are not licensed for use in children. Metoclopramide is contraindicated in infants, and should only be prescribed for short-term use (up to 5 days). For licensing and prescribing information, refer to the individual SPCs and BNF for children. MHRA drug safety updates have been issued covering risk of cardiac side-effects with domperidone and risk of neurological adverse events with metoclopramide.3

Further management options can include enteral feeding and surgery (fundoplication).3

7. Consider whether the child needs investigation

Diagnostic investigations are generally not necessary, as accuracy of these tests remains unclear and they have not been found to be more reliable than the history and examination for diagnosing GOR or GORD.11

Diagnostic tests would be arranged under the care of paediatricians. These would possibly include oesophageal pH studies, upper gastrointestinal (GI) contrast studies, or endoscopies.3

8. Know when to refer

A child presenting with haematemesis (blood-stained vomit), melaena (black, foul-smelling stool), or dysphagia should be referred and seen the same day (see also Table 2, above).3,6

Infants and children with any of the following should be referred for specialist assessment by a paediatrician or paediatric gastroenterologist:6

  • an uncertain diagnosis or the presence of ‘red flag’ features which suggest a more serious condition (see Table 2, above)
  • persistent, faltering growth associated with regurgitation
  • unexplained distress in children with communication difficulties
  • symptoms suggestive of GORD not responding to (or needing ongoing) medical treatment
  • feeding aversion and a history of regurgitation
  • unexplained iron deficiency anaemia
  • no improvement in regurgitation after 1 year of age
  • suspected Sandifer’s syndrome (characterised by episodic torticollis with neck extension and rotation).

A child should also be referred to a paediatrician or paediatric gastroenterologist if there are suspected complications as a result of GOR/GORD. These include:6

  • suspected recurrent aspiration pneumonia
  • unexplained apnoeas
  • unexplained epileptic seizure-like events
  • unexplained upper airway inflammation
  • dental erosion in a child with a neurodisability, in particular cerebral palsy
  • recurrent acute otitis media (more than three episodes in 6 months).

9. Advise about symptoms that should prompt review

If the parents/carers have been reassured that their child has GOR and does not require any further intervention, or if the child has been diagnosed with GORD and treatment started, they should be advised to return for review if any of the following occur:3,6

  • the regurgitation becomes persistently projectile
  • there is bile-stained (green or yellow-green) vomiting or haematemesis
  • 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.

It is important when treatment is started that the children are followed up. This is to check the continued requirement for the medication. It is also so that children who are not responding to treatment are identified earlier and appropriate actions taken.

It is also important to remember the possible complications of GOR in infants, children, and young people. These can include recurrent aspiration pneumonia, frequent otitis media, reflux oesophagitis, and dental erosion in a child or young person with a neurodisability.2,6 Children may present with these as the first signs of GOR.

10. Remember that babies gain weight

When reviewing the child and how they are responding to treatment, it is important to remember that over time they will be gaining weight and so may require fairly frequent medication adjustments. The weight change can be helpful as they get older and are likely to become less troubled with symptoms, as they can effectively slowly wean off the medication as they gain weight.

Summary

GOR is a very common condition and is regularly seen in general practice. GORD is less common, but may require further treatment and intervention. The management should include a thorough assessment of an infant’s feeding, and if adjustments have not been helpful then medication may be required.

Dr Jennifer Parkhouse

GP, Harrogate

GPwSI in Paediatrics

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After reading this article, ‘Test and reflect’ on your updated knowledge with our patient scenarios. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

  1. Baird D, Harker D, Karmes A. Diagnosis and treatment of gastrooesphageal reflux in infants and children. Am Fam Physician 2015; 92 (8): 705–714.
  2. NICE. Gastro-oesphageal reflux in children and young people. Quality standard 112. NICE, 2016. Available at: www.nice.org.uk/qs112
  3. NICE. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NICE Guideline 1. NICE, 2015 (last updated October 2019). Available at: www.nice.org.uk/ng1
  4. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-esophageal reflux in children. Intl J Mol Sci 2017; 18 (8): 1671.
  5. Nelson S, Chen E, Syniar G, Christoffel K. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Arch Pediatr Adolesc Med 2000; 154 (2): 150–154.
  6. NICE. GORD in children. Clinical Knowledge Summary. cks.nice.org.uk/gord-in-children (accessed 9 March 2020).
  7. NICE. Food allergy in under 19s: assessment and diagnosis. Clinical Guideline 116. NICE, 2011. Available at: www.nice.org.uk/cg116
  8. Salvatore S, Abkari A, Cai W et al. Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants. Acta Paediatr 2018; 107 (9): 1512–1520.
  9. NHS website. Sudden infant death syndrome (SIDS). www.nhs.uk/conditions/sudden-infant-death-syndrome-sids/ (accessed 9 March 2020).
  10. DHSC, NHS. Ranitidine: all formulations. Supply disruption alert—second update. Medicines and Healthcare products Regulatory Agency, 2019. Available at: www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102952
  11. van der Pol R, Smits M, Venmans L et al. Diagnostic accuracy of tests in pediatric gastroesophageal reflux disease. J Pediatr 2013; 162 (5): 983–987.