Quality standard
Quality statement 9: 'Red flag' symptoms and suggested actions
Quality statement 9: 'Red flag' symptoms and suggested actions
Quality statement
Infants, children and young people with vomiting or regurgitation and any 'red flag' symptoms are referred to specialist care with investigations as appropriate.
Rationale
Some symptoms that are commonly mistaken for gastro‑oesophageal reflux disease (GORD) may be 'red flag' symptoms for other problems. These problems need action to be taken, such as further investigations or specialist referral.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that infants, children and young people with vomiting or regurgitation and any 'red flag' symptoms are further investigated or referred to specialist care with investigations as appropriate.
Data source: Local data collection.
Process
a) Proportion of infants, children and young people with vomiting or regurgitation and any 'red flag' symptoms who had further investigations and specialist referral.
Numerator – number in the denominator who had further investigations and specialist referral.
Denominator – number of infants, children and young people presenting with vomiting or regurgitation and any 'red flag' symptoms.
Data source: Local data collection.
b) Proportion of infants, children and young people with vomiting or regurgitation and any 'red flag' symptoms who had appropriate investigations and specialist referral.
Numerator – number in the denominator who had appropriate investigations and specialist referral.
Denominator – number of infants, children and young people with vomiting or regurgitation and any 'red flag' symptoms who had further investigations and specialist referral.
Data source: Local data collection.
What the quality statement means for different audiences
Service providers ensure that there are practice arrangements and written clinical protocols to ensure that healthcare professionals look out for 'red flag' symptoms in infants, children and young people with vomiting or regurgitation, and carry out further investigations or arrange specialist referrals depending on the symptoms.
Healthcare professionals (midwives, paediatric nurses or GPs) look out for 'red flag' symptoms in infants, children and young people with vomiting or regurgitation and carry out further investigations or arrange specialist referrals depending on the symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that services they commission have pathways for healthcare professionals to carry out further investigations or arrange specialist referrals for infants, children and young people with vomiting or regurgitation and 'red flag' symptoms.
Infants, children and young people have tests or are referred to a specialist if their symptoms show that they might have another problem than reflux.
Source guidance
Gastro-oesophageal reflux disease in children and young people. NICE guideline NG1 (2015, updated 2019), recommendation 1.1.5 (key priority for implementation)
Definitions of terms used in this quality statement
|
Gastrointestinal 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 |
|
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 or persisting after 1 year |
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) 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) 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) |
Specialist referral |
|
Systemic symptoms and signs |
Possible diagnostic implications |
Suggested actions |
|
Appearing unwell Fever |
May suggest infection (also see the NICE guideline on fever in under 5s) |
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 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) |
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) |
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) |
Specialist referral |