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

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 (2015) NICE guideline NG1, recommendation 1.1.5 (key priority for implementation)

Definitions of terms used in this quality statement

'Red flag' symptoms and suggested actions

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 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

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