Management of Gastro-oesophageal reflux disease in children: NICE Guidelines
NICE has released its 2019 guidelines on the management of Gastro-oesophageal reflux disease in children which is an update on 2010 guidelines.
Gastro‑oesophageal reflux (GOR) is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, gastro‑oesophageal reflux disease (GORD) occurs when the effect of GOR leads to symptoms severe enough to merit medical treatment. GOR is more common in infants than in older children and young people, and it is noticeable by the effortless regurgitation of feeds in young babies.
Following are the major recommendations:
1. 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 to using clinical judgment.
Table 1 'Red flag' symptoms suggesting disorders other than GOR
- 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 family history. If a non‑IgE‑mediated cows' milk protein allergy is suspected, see the NICE guideline on food allergy in under 19s.
- 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 pediatric 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).
- Do not offer an upper gastrointestinal (GI) contrast study to diagnose or assess the severity of GORD in infants, children and young people.
- Perform an urgent (same day) upper GI contrast study for infants with unexplained bile‑stained vomiting. Explain to the parents and carers that this is needed to rule out serious disorders such as intestinal obstruction due to mid‑gut volvulus.
- Consider an upper GI contrast study for children and young people with a history of bile‑stained vomiting, particularly if it is persistent or recurrent.
- Offer an upper GI contrast study for children and young people with a history of GORD presenting with dysphagia.
- 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 history of regurgitation
- unexplained iron‑deficiency anaemia
- a suspected diagnosis of Sandifer's syndrome.
- Consider performing an oesophageal pH study (or combined oesophageal pH and impedance monitoring if available) in infants, children and young people with:
- suspected recurrent aspiration pneumonia
- unexplained apnoeas
- unexplained non‑epileptic seizure‑like events
- unexplained upper airway inflammation
- dental erosion associated with a neurodisability
- frequent otitis media
- a possible need for fundoplication (see section 1.5)
- a suspected diagnosis of Sandifer's syndrome.
- Consider performing an oesophageal pH study without impedance monitoring in infants, children and young people if, using clinical judgement, it is thought necessary to ensure effective acid suppression.
- 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.
2. 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 (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 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 (see recommendation 1.2.3), 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.
3. 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 [2] 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[2] 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[2], 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[2], 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[2] 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[3] to treat GOR or GORD unless all of the following conditions are met:
- the potential benefits outweigh the risk of adverse events
- other interventions have been tried
- there is a specialist paediatric healthcare professional agreement for its use.
4. Enteral tube feeding for GORD
- Only consider enteral tube feeding to promote weight gain in infants and children with overt regurgitation and faltering growth if:
- other explanations for poor weight gain have been explored and/or
- recommended feeding and medical management of overt regurgitation are unsuccessful.
- Before starting enteral tube feeding for infants and children with faltering growth associated with overt regurgitation, agree in advance:
- a specific, individualised nutrition plan
- a strategy to reduce it as soon as possible
- an exit strategy, if appropriate, to stop it as soon as possible.
- In infants and children receiving enteral tube feeding for faltering growth associated with overt regurgitation:
- provide oral stimulation, continuing oral feeding as tolerated
- follow the nutrition plan, ensuring that the intended target weight is achieved and that appropriate weight gain is sustained
- reduce and stop enteral tube feeding as soon as possible.
- Consider jejunal feeding for infants, children and young people:
- who need enteral tube feeding but who cannot tolerate intragastric feeds because of regurgitation or
- if reflux‑related pulmonary aspiration is a concern.
5. Surgery for GORD
- Offer an upper GI endoscopy with oesophageal biopsies for infants, children and young people before deciding whether to offer fundoplication for presumed GORD.
- Consider performing other investigations such as an oesophageal pH study (or combined oesophageal pH and impedance monitoring if available) and an upper GI contrast study for infants, children and young people before deciding whether to offer fundoplication.
- Consider fundoplication in infants, children and young people with severe, intractable GORD if:
- appropriate medical treatment has been unsuccessful or
feeding regimens to manage GORD prove impractical, for example, in the case of long‑term, continuous, thickened enteral tube feeding.
For more details click on the link: nice.org.uk
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