Nice | Gatroesophageal Reflux Disease (GORD) in Children

This is a new guideline from Nice on the management of GORD in infants and children.

The main differences from common practice is that they advice that PPI or H2 antagonists are only used if other specific symptoms are present too (see below). Most children with isolated GORD need no treatment.

GORD in infants

Reassure parents that gastroesophageal reflux is a normal process. GORD (where it causes symptoms) is present in 40% of infants. Most therefore need no treatment and just reassurance that it will get better with time.

Advise parents to attend for review if:

  • there are still frequent symptoms by 1 yr
  • they get persistent projectile vomiting
  • it becomes yellow or green or with blood
  • there are other new concerns (eg faltering growth, marked distress or feeding difficulties)

Referral criteria

Children should be referred if there is:

  • haematemesis or melaena
  • dysphagia
  • no improvement by 1 yr of age
  • persistent faltering growth with overt reflux
  • unexplained distress in children with communication problems
  • ongoing symptoms despite treatment
  • feeding aversion with reflux
  • unexplained iron deficiency anaemia
  • suspected Sandifers Syndrome (beware children with reflux who have abnormal neck movements after feeding)
  • complications of GORD (eg aspiration pneumonia, dental erosion, frequent otitis media (3 times in 6m), apnoea or oesophagitis)

Management

If breastfed

  • Advise a feeding assessment initially.
  • If this does not help, trial an alginate for 1 to 2 weeks and continue it if it helps.

If formula fed

  • Ensure that correct volumes are being used.
  • Trial smaller more frequent feeds.
  • If this doesn't help, trial a thickened formula.
  • If this doesn't help, stop it and trial an alginate for 1 to 2 weeks and continue it if it helps.

Both breastfed and formula fed babies where alginates don't help

Trial a PPI or H2 antagonist for 4 weeks if there is overt reflux AND at least one of:

  • unexplained feeding difficulties (eg choking, gagging or refusing feeds)
  • faltering growth
  • distressed behaviour

DO NOT offer PPI or H2 antagonists where GORD is an isolated problem.

These same criteria can be used for deciding when to treat children with communication problems.

Children with symptoms

You can trial a PPI or H2 antagonist if there is:

  • heartburn
  • epigastric pain

 

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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1 Response

  1. sara
    Thank you for this very helpful and practical summary. I hadn't realised here was a link between GORD and otitis media.

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