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 to treat GOR or GORD without seeking specialist advice and taking into account their potential to cause adverse events.

  • National Institute for Health and Care Excellence (NICE)