Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

  • Give advice about gastro‑oesophageal reflux (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.

  • 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.

  • 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.

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

  • 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.

  • 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 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.

  • 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.

  • Do not offer metoclopramide, domperidone or erythromycin[1] 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 specialist paediatric healthcare professional agreement for its use.



[1] 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 see 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.

  • National Institute for Health and Care Excellence (NICE)