Gastro-Oesophageal Reflux Disease (GORD) in Children
NICE guideline [NG1] Gastro-oesophageal reflux disease in children and young people: diagnosis and management. Last updated: Oct 2019.
Background Information
Definition
GOR:
- Passage of gastric content into the oesophagus
- Common physiological event
- Often asymptomatic and associated with overt regurgitation (visible regurgitation of feeds)
GORD:
- GOR that causes symptoms (e.g. discomfort or pain)
Risk Factors
- Premature birth
- Obesity
- Hiatus hernia
- Congenital diaphragmatic hernia (repaired)
- Congenital oesophageal atresia (repaired)
- Neurodisability
- Parental history of heartburn / acid regurgitation
- Asthma (but not been shown to cause it or worsen it)
Clinical Features
Possible clinical features:
- Heart burn / retrosternal pain / epigastric pain
- Feeding difficulties (e.g. refusing to feed, gagging, choking, regurgitation)
- Hoarseness
- Cough
- Faltering growth
Red Flags
Presence of the following red flags suggests disorders other than GOR:
| Feature | Possible implication |
|---|---|
| Frequent projectile vomiting | Hypertrophic pyloric stenosis |
| Bile-stained vomit | Intestinal obstruction |
| Abdominal distension / tenderness / palpable mass | |
| Haematemesis | Upper GI bleed |
| Blood in stool | Lower GI bleed Cows' milk protein allergy Bacterial gastroenteritis |
| Chronic diarrhoea | Cows' milk protein allergy |
| Late onset (>8 weeks) | UTI |
Complications
Possible complications:
- Reflux oesophagitis
- Aspiration pneumonia
- Otitis media
- Dental erosion
Diagnosis Guidelines
Investigation and Diagnosis
Clinical diagnosis is sufficient in most cases.
Investigations should not be performed routinely
| Investigation | Indications |
|---|---|
| Upper GI endoscopy + biopsy | Specialist hospital assessment with possible endoscopy if:
|
| Upper GI contrast study | To exclude anatomical abnormalities
Consider if:
|
| Oesophageal pH study | Gold standard test to confirm GOR
Consider if there are unexplained complications of GOR:
|
Investigation for UTI should be considered if there is late onset GOR (>8 weeks old) + faltering growth + frequent regurgitation and marked distress.
UTI typically present non-specifically in young patients, vomiting or reflux-like symptoms may reflect systemic illness like UTI rather than primary GOR.
Management Guidelines
Patient / Carer Education
Advise that:
- Very common (affects at least 40% of infants)
- Episodes may be frequent (5% of those affected have 6 or more episodes each day)
- Usually becomes less frequent with time (resolves in 90% of affected infants before 1 y/o)
- Does not usually need further investigation or treatment
General / Conservative Management
Always attempt general / conservative management first, and only proceed to pharmacological management if these fail.
Breast-Fed Infants
Carry out a breastfeeding assessment and advice
Formula-Fed Infants
Review feeding history:
- Reduce feed volumes only if excessive for infant's weight
- Trial of smaller but more frequent feeds (while maintaining an appropriate total daily amount of milk)
- If the above failed, offer a trial of thickened formula (e.g. containing rice starch, cornstarch, locust bean gum, carob bean gum)
Pharmacological Management
1st line: alginate therapy (trial of 1-2 weeks)
Do not offer PPI or H2 receptor antagonist to treat isolated regurgitation
Consider 4-week trial of PPI or H2 receptor antagonist if:
- Unable to communicate about their symptoms (e.g. very young, communication difficulties) with feeding difficulties / faltering growth / distressed behaviour
- Persistent heartburn / retrosternal / epigastric pain
- Endoscopy-proven reflux oesophagitis
Further Management
Further management options include:
- Enteral feeding (esp. in faltering growth)
- Surgery – fundoplication (last resort)
- Offer upper GI endoscopy and consider other investigations before considering fundoplication