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["Baseline assessment: Gastro-"]
["oesophageal reflux disease in children"]
["and young people "]
["NG1"]
[]
["Published: January 2015"]
["Updated: October 2019"]

{"sheet":"Introduction","index":1,"n_rows":23,"n_cols":1,"rows_kept":23,"cut":false,"hidden":false,"merged":[]}
["Baseline assessment tool for Gastro-oesophageal reflux disease in children and young people (NICE clinical guideline NG1)"]
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["This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Gastro-oesophageal reflux disease in children and young people.  It can also help to plan activity to meet the recommendations."]
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["The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
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["It should be used in conjunction with Gastro-oesophageal reflux disease in children and young people (NICE clinical guideline NG1)."]
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["In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
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["Is the guideline relevant?"]
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["The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
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["The table can be adapted to include any other local information that is thought to be useful."]
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["If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
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["Tools and resources to help put the guidance into practice are available on the NICE website. "]
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["National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2021. All rights reserved. Subject to Notice of rights.\n"]

{"sheet":"Data sheet","index":2,"n_rows":55,"n_cols":11,"rows_kept":55,"cut":false,"hidden":false,"merged":[]}
["Baseline assessment tool for Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people (NICE clinical guideline NG1)"]
[]
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[null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(F8:F55,\"Yes\")","v":0}]
[null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(F4/F3),\"\",F4/F3)","v":""}]
[]
["NICE recommendation","Guideline reference","Year of recommendation","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
["1.1 Diagnosing and investigating GORD"]
["Recognise regurgitation of feeds as a common and normal occurrence in infants that:\n• is due to gastro-oesophageal reflux (GOR) – a normal physiological process in infancy\n• does not usually need any investigation or treatment\n• is managed by advising and reassuring parents and carers.","1.1.1"]
["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).","1.1.2"]
["Give advice about GOR and reassure parents and carers that in well infants, effortless regurgitation of feeds:\n• is very common (it affects at least 40% of infants)\n• usually begins before the infant is 8 weeks old \n• may be frequent (5% of those affected have 6 or more episodes each day)\n• usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year old)\n• does not usually need further investigation or treatment.","1.1.3"]
["When reassuring parents and carers about regurgitation, advise them that they should return for review if any of the following occur:\n• the regurgitation becomes persistently projectile\n• there is bile-stained (green or yellow-green) vomiting or haematemesis (blood in vomit)\n• there are new concerns, such as signs of marked distress, feeding difficulties or faltering growth\n• there is persistent, frequent regurgitation beyond the first year of life.","1.1.4"]
["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.","1.1.5"]
["Do not routinely investigate or treat for GOR if an infant or child without overt regurgitation presents with only 1 of the following:\n• unexplained feeding difficulties (for example, refusing to feed, gagging or choking)\n• distressed behaviour\n• faltering growth\n• chronic cough\n• hoarseness\n• a single episode of pneumonia.","1.1.6"]
["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.","1.1.7"]
["Recognise the following as possible complications of GOR in infants, children and young people:\n• reflux oesophagitis\n• recurrent aspiration pneumonia\n• frequent otitis media (for example, more than 3 episodes in 6 months)\n• dental erosion in a child or young person with a neurodisability, in particular cerebral palsy.","1.1.8"]
["Recognise the following as possible symptoms of GOR in children and young people:\n• heartburn\n• retrosternal pain\n• epigastric pain.","1.1.9"]
["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.","1.1.10"]
["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 under 19s.","1.1.11"]
["When deciding whether to investigate or treat, take into account that the following are associated with an increased prevalence of GORD:\n• premature birth\n• parental history of heartburn or acid regurgitation\n• obesity\n• hiatus hernia\n• history of congenital diaphragmatic hernia (repaired)\n• history of congenital oesophageal atresia (repaired)\n• a neurodisability.","1.1.12"]
["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.","1.1.13"]
["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).","1.1.14"]
["Do not offer an upper gastrointestinal (GI) contrast study to diagnose or assess the severity of GORD in infants, children and young people.","1.1.15"]
["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.","1.1.16"]
["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.","1.1.17"]
["Offer an upper GI contrast study for children and young people with a history of GORD presenting with dysphagia.","1.1.18"]
["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.","1.1.19"]
["Arrange a specialist hospital assessment for infants, children and young people for a possible upper GI endoscopy with biopsies if there is: \n• haematemesis (blood-stained vomit) not caused by swallowed blood (assessment to take place on the same day if clinically indicated; also see table 1)\n• melaena (black, foul-smelling stool; assessment to take place on the same day if clinically indicated; also see table 1)\n• dysphagia (assessment to take place on the same day if clinically indicated)\n• no improvement in regurgitation after 1 year old \n• persistent, faltering growth associated with overt regurgitation \n• unexplained distress in children and young people with communication difficulties\n• retrosternal, epigastric or upper abdominal pain that needs ongoing medical therapy or is refractory to medical therapy \n• feeding aversion and a history of regurgitation \n• unexplained iron-deficiency anaemia \n• a suspected diagnosis of Sandifer's syndrome. ","1.1.20"]
["Consider performing an oesophageal pH study (or combined oesophageal pH and impedance monitoring if available) in infants, children and young people with:\n• suspected recurrent aspiration pneumonia \n• unexplained apnoeas \n• unexplained non-epileptic seizure-like events\n• unexplained upper airway inflammation\n• dental erosion associated with a neurodisability\n• frequent otitis media\n• a possible need for fundoplication (see the recommendations in the section on surgery for GORD )\n• a suspected diagnosis of Sandifer's syndrome.","1.1.21"]
["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.","1.1.22"]
["Investigate the possibility of a urinary tract infection in infants with regurgitation if there is:\n• faltering growth\n• late onset (after the infant is 8 weeks old)\n• frequent regurgitation and marked distress.","1.1.23"]
["1.2 Initial management of GOR and GORD"]
["Do not use positional management to treat GOR in sleeping infants. In line with NHS advice on sudden infant death syndrome (SIDS), infants should be placed on their back when sleeping.","1.2.1"]
["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.","1.2.2"]
["In formula-fed infants with frequent regurgitation associated with marked distress, use the following stepped-care approach:\n• review the feeding history, then\n• reduce the feed volumes only if excessive for the infant's weight, then\n• 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\n• offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum).","1.2.3"]
["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.","1.2.4"]
["In formula-fed infants, if the stepped-care approach is unsuccessful (see the recommendation on stepped-care approach for formula fed infants with frequent regurgitation associated with marked distress), 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.","1.2.5"]
["1.3 Pharmacological treatment of GORD"]
["Not all PPIs and H2RAs are licensed for use in children and those that are licensed vary in the age that they are licensed from. For licensing and prescribing information see the individual SPCs and BNF for children. MHRA drug safety updates have been issued for PPIs, covering hypomagnesaemia, increased risk of fracture with long-term use and very low risk of subacute cutaneous lupus erythematosus."]
["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.","1.3.1"]
["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:\n• unexplained feeding difficulties (for example, refusing feeds, gagging or choking)\n• distressed behaviour\n• faltering growth.","1.3.2"]
["Consider a 4 week trial of a PPI or H2RA for children and young people with persistent heartburn, retrosternal or epigastric pain.","1.3.3"]
["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:\n• do not resolve or\n• recur after stopping the treatment.","1.3.4"]
["When choosing between PPIs and H2RAs, take into account:\n• the availability of age-appropriate preparations\n• the preference of the parent (or carer), child or young person (as appropriate)\n• local procurement costs.","1.3.5"]
["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. ","1.3.6"]
["Do not offer metoclopramide, domperidone or erythromycin to treat GOR or GORD unless all of the following conditions are met:\n•\tthe potential benefits outweigh the risk of adverse events\n•\tother interventions have been tried\n•\tthere is specialist paediatric healthcare professional agreement for its use.\n\nMetoclopramide, 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, risk of neurological adverse events with metoclopramide, risk of infantile hypertrophic pyloric stenosis with erythromycin, cardiac risks (QT interval prolongation) with erythromycin and potential drug interaction of erythromycin with rivaroxaban. ","1.3.7"]
["1.4 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:\n• other explanations for poor weight gain have been explored and/or\n• recommended feeding and medical management of overt regurgitation is unsuccessful. ","1.4.1"]
["Before starting enteral tube feeding for infants and children with faltering growth associated with overt regurgitation, agree in advance:\n• a specific, individualised nutrition plan \n• a strategy to reduce it as soon as possible \n• an exit strategy, if appropriate, to stop it as soon as possible.","1.4.2"]
["In infants and children receiving enteral tube feeding for faltering growth associated with overt regurgitation:\n• provide oral stimulation, continuing oral feeding as tolerated\n• follow the nutrition plan, ensuring that the intended target weight is achieved and that appropriate weight gain is sustained\n• reduce and stop enteral tube feeding as soon as possible.","1.4.3"]
["Consider jejunal feeding for infants, children and young people: \n• who need enteral tube feeding but who cannot tolerate intragastric feeds because of regurgitation or \n• if reflux-related pulmonary aspiration is a concern. ","1.4.4"]
["1.5 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.","1.5.1"]
["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.","1.5.2"]
["Consider fundoplication in infants, children and young people with severe, intractable GORD if:\n• appropriate medical treatment has been unsuccessful or\n• feeding regimens to manage GORD prove impractical, for example, in the case of long term, continuous, thickened enteral tube feeding.","1.5.3"]

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["Table 1 ‘Red flag’ symptoms suggesting disorders other than GOR"]
["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 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 under 16s).\nPersistence suggests an alternative diagnosis ","Urine microbiology investigation\nSpecialist 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\nSpecialist referral\n"]
["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"]
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["Systemic symptoms and signs","Possible diagnostic implications","Suggested actions"]
["Appearing unwell\nFever","May suggest infection (also see the NICE guideline on fever in under 5s)","Clinical assessment and urine microbiology investigation \nSpecialist 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 \nSpecialist 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)\nPersistent 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"]