1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

Terms used in this guideline

Infants, children and young people are defined as follows:

  • infants: under 1 year

  • children: 1 to under 12 years

  • young people: 12 to under 18 years.

Gastro‑oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is a common physiological event that can happen at all ages from infancy to old age, and is often asymptomatic. It occurs more frequently after feeds/meals. In many infants, GOR is associated with a tendency to 'overt regurgitation' – the visible regurgitation of feeds.

Gastro‑oesophageal reflux disease (GORD) refers to gastro‑oesophageal reflux that causes symptoms (for example, discomfort or pain) severe enough to merit medical treatment, or to gastro‑oesophageal reflux‑associated complications (such as oesophagitis or pulmonary aspiration). In adults, the term GORD is often used more narrowly, referring specifically to reflux oesophagitis.

Marked distress There is very limited evidence, and no objective or widely accepted clinical definition, for what constitutes 'marked distress' in infants and children who are unable to adequately communicate (expressively) their sensory emotions. In this guideline, 'marked distress' refers to an outward demonstration of pain or unhappiness that is outside what is considered to be the normal range by an appropriately trained, competent healthcare professional, based on a thorough assessment. This assessment should include a careful analysis of the description offered by the parents or carers in the clinical context of the individual child.

Occult reflux refers to the movement of part or all of the stomach contents up the oesophagus, but not to the extent that it enters the mouth or is obvious to the child, parents or carers, or observing healthcare professional. There is no obvious, visible regurgitation or vomiting. It is sometimes referred to as silent reflux.

Overt regurgitation refers tothe voluntary or involuntary movement of part or all of the stomach contents up the oesophagus at least to the mouth, and often emerging from the mouth. Regurgitation is in principle clinically observable, so is an overt phenomenon, although lesser degrees of regurgitation into the mouth might be overlooked.

Specialist refers to a paediatrician with the skills, experience and competency necessary to deal with the particular clinical concern that has been identified by the referring healthcare professional. In this guideline this is most likely to be a consultant general paediatrician. Depending on the clinical circumstances, 'specialist' may also refer to a paediatric surgeon, paediatric gastroenterologist or a doctor with the equivalent skills and competency.

1.1 Diagnosing and investigating GORD

1.1.1 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.

1.1.2 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).

1.1.3 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.

1.1.4 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.

1.1.5 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 using clinical judgement.

Table 1 'Red flag' symptoms suggesting disorders other than GOR

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 children)

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 children and young people) 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 children and young people)

Specialist referral

Systemic

Appearing unwell

Fever

May suggest infection (also see the NICE guideline on feverish illness in children)

Clinical assessment and urine microbiology investigation

Specialist referral

Dysuria

May suggest urinary tract infection (also see the NICE guideline on urinary tract infection in children)

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 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

Altered responsiveness, for example, lethargy or irritability

May suggest an illness such as meningitis (also see the NICE guideline on bacterial meningitis and meningococcal septicaemia)

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 children and young people)

Specialist referral

1.1.6 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.

1.1.7 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.

1.1.8 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.

1.1.9 Recognise the following as possible symptoms of GOR in children and young people:

  • heartburn

  • retrosternal pain

  • epigastric pain.

1.1.10 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.

1.1.11 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 a family history. If a non‑IgE‑mediated cows' milk protein allergy is suspected, see the NICE guideline on food allergy in children and young people.

1.1.12 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.

1.1.13 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 paediatric assessment.

1.1.14 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).

1.1.15 Do not offer an upper gastrointestinal (GI) contrast study to diagnose or assess the severity of GORD in infants, children and young people.

1.1.16 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.

1.1.17 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.

1.1.18 Offer an upper GI contrast study for children and young people with a history of GORD presenting with dysphagia.

1.1.19 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.

1.1.20 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 a history of regurgitation

  • unexplained iron‑deficiency anaemia

  • a suspected diagnosis of Sandifer's syndrome.

1.1.21 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.

1.1.22 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.

1.1.23 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.

1.2 Initial management of GOR and GORD

1.2.1 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.

1.2.2 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.

1.2.3 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).

1.2.4 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.

1.2.5 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.

1.3 Pharmacological treatment of GORD

1.3.1 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.

1.3.2 Consider a 4‑week trial of a PPI or H2RA 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.

1.3.3 Consider a 4‑week trial of a PPI or H2RA for children and young people with persistent heartburn, retrosternal or epigastric pain.

1.3.4 Assess the response to the 4‑week trial of the PPI or H2RA, and consider referral to a specialist for possible endoscopy if the symptoms:

  • do not resolve or

  • recur after stopping the treatment.

1.3.5 When choosing between PPIs and H2RAs, 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.

1.3.6 Offer PPI or H2RA treatment to infants, children and young people with endoscopy‑proven reflux oesophagitis, and consider repeat endoscopic examinations as necessary to guide subsequent treatment.

1.3.7 Do not offer metoclopramide, domperidone or erythromycin to treat GOR or GORD without seeking specialist advice and taking into account their potential to cause adverse events.

1.4 Enteral tube feeding for GORD

1.4.1 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 is unsuccessful.

1.4.2 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.

1.4.3 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.

1.4.4 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.

1.5 Surgery for GORD

1.5.1 Offer an upper GI endoscopy with oesophageal biopsies for infants, children and young people before deciding whether to offer fundoplication for presumed GORD.

1.5.2 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.

1.5.3 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.

  • National Institute for Health and Care Excellence (NICE)