NICE sets out new advice to treat gastro-oesophageal reflux disease (GORD) more effectively.
Healthcare professionals should reassure parents that reflux is very common in well infants and does not require treatment, but should be alert to red flag symptoms which may suggest GORD or other disorders.
Bringing up food is a common physiological process that usually happens after eating in healthy infants, children, and young people. It is most common in babies – affecting 4 in 10 infants – but can happen to almost everyone at some point in their lives.
GORD refers to gastro-oesophageal reflux (GOR), which is so severe that medical treatment is required i.e. complications from GOR have arisen.
However, it is difficult to differentiate between GOR and GORD, and the terms are used interchangeably by health professionals and families alike.
GORD affects many children and families in the UK, who commonly seek medical advice and as a result, it places a health burden on the NHS.
NICE recommends that parents and carers are given advice about GOR and are reassured that in well infants, effortless regurgitation of feeds is very common, usually begins before the infant is 8 weeks old, but will become less frequent with time and does not usually need further investigation or treatment. Health professionals should support and advise families on the difference between GOR and GORD.
Professor Mark Baker, Director for the Centre for Clinical Practice at NICE, has been quoted as saying on the NICE web page specific to information on this topic: “It can be difficult to differentiate between ‘normal’ episodes of reflux and more serious GORD, but this new NICE guideline will support medical professionals to make the correct diagnosis. It will mean infants, children and young people get the care that they need while also avoiding over-treating healthy children.
"GOR and GORD in infants, children and young people, although common, can be very distressing. Parents and carers can feel helpless and may feel like their fears or concerns are being dismissed. Healthcare professionals should reassure families but also take all concerns seriously. If not treated, GORD can lead to malnutrition in children, cause ulcers in the oesophagus and can have psychological effects on a child’s relationship with food. GORD can be treated well with medication, so specialist referrals should be given to those children whose symptoms persist."
Red flag symptoms
NICE recommends that health professionals look for ‘red flag’ symptoms which may suggest disorders other than GOR and investigate further or refer.
Some of the ‘Red flag’ symptoms suggesting disorders other than GOR:
|Symptoms and signs||Possible diagnostic implications||Suggested actions|
|Frequent, forceful (projectile) vomiting||May suggest hypertrophic pyloric stenosis in infants up to 2 months old||Paediatric surgery referral|
|Abdominal distension, tenderness or palpable mass||May suggest intestinal obstruction or another acute surgical condition||Paediatric surgery referral|
|Chronic diarrhoea||May suggest cow’s milk protein allergy (also see the NICE guideline on food allergy in children and young people)||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) 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|
Health professionals should 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
- a single episode of pneumonia
NICE recommends using a stepped-care approach for formula-fed infants with frequent regurgitation associated with marked distress.
Health professionals should review the feeding history then reduce the feed volumes only if excessive for the infant's weight. They should then offer a trial of smaller, more frequent feeds , unless the feeds are already small and frequent, then offer a trial of thickened formula, such as those containing rice starch, cornstarch, locust bean gum or carob bean gum.
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.
Don’t offer acid-suppressing drugs
Proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) should not be offered to treat overt regurgitation in infants and children occurring as an isolated symptom.
NICE also recommends against offering metoclopramide, domperidone or erythromycin to treat GOR or GORD without seeking specialist advice and taking into account their potential to cause adverse events.
- Allergic gut problems
- Anal fissures
- Bacterial overgrowth
- Coeliac disease
- Common liver problems
- Common pancreatic problems
- Constipation and Hirschsprung’s disease
- Crohns disease
- Eosinophilic oesophagitis
- Faltering growth
- Feeding disorders
- Gastro-oesophageal reflux
- Gut blood loss and anaemia
- Gut infections
- Infant colic
- Inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis)
- Lactose intolerance