Gastro-oesophageal Reflux Disease (GORD) in Children Care Pathway Overview

This pathway covers the management of Gastro-oesophageal Reflux Disease only. 

is the passage of gastric contents into the oesophagus. It is a common physiological event that can happen at all ages from infancy to old age, and is often asymptomatic. It occurs more frequently after feeds/meals. In many infants, GOR is associated with a tendency to 'overt regurgitation' – the visible regurgitation of feeds. 

refers to gastro-oesophageal reflux that causes symptoms (for example, discomfort or pain) severe enough to merit medical treatment, or to gastro-oesophageal reflux-associated complications (such as oesophagitis or pulmonary aspiration). In adults, the term GORD is often used more narrowly, referring specifically to reflux oesophagitis.

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Presentation

GORD is the passage of gastric contents into the oesophagus causing troublesome symptoms and/or complications.

  • Regurgitation of a significant volume of feed
  • reluctance to feed
  • Distress/crying at feed times
  • Small volumes of feed being taken.

  • Irritability when lying flat
  • Weight loss
  • Arching of the back
  • Dehydration

Red Flags
  • Faltering Growth
  • Haematemesis (vomiting of blood - not caused by swallowed blood from a nosebleed or a cracked nipple).
  • Melaena (black, foul-smelling stool).
  • Dysphagia  (difficulty or discomfort in swallowing)

Contact Paediatric Consultant on call to discuss and/or arrange urgent admission

Differential Diagnosis

Offer reassurance and advise 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 of age).
  • Treatment or further investigation is not normally required.

Review infant or child if:

  • Regurgitation becomes persistently projectile — admission is required.
  • There is bile-stained vomiting or haematemesis — admission is required.
  • There are new concerns, such as signs of marked distress, feeding difficulties, or faltering growth — suggests a diagnosis of gastro-oesophageal reflux
  • There is persistent, frequent regurgitation beyond the first year of life

See Cow’s Milk Protein Allergy pathway

See Lactose Intolerance pathway

See Faltering Growth pathway
Initial Primary Care Assessment
  • If the infant is thriving and not distressed reassure parents and monitor.
  • Provide advice on avoidance of overfeeding, positioning during and after feeding, and activity after feeding.
  • Diagnosis is made from history that may include effortless vomiting (not projectile) after feeding, usually in the first 6 months of life, and usually resolves spontaneously by 12-15 months age.
  • It should be noted that 50% of babies have some degree of reflux at some time.
  • Overfeeding needs to be ruled out by establishing the volume and frequency of feeds. Average requirements of formula are 150mls/kg/day for babies up to 6 months, and should be offered spread over 6-7 feeds.
Initial Primary Care Management

Breast-fed infant with frequent regurgitation and marked distress

  • 1-2 week trial with Infant Gaviscon® offered on a spoon before feeds.

 

If still symptomatic despite regular Infant Gaviscon

  • 4-week trial of proton pump inhibitors (PPIs) or ranitidine, if improvement continue with regular treatment breaks/reviews

 

Review after 1 month:

If symptoms still persist despite the above interventions refer to a paediatrician or paediatric gastroenterologist

Please follow the Countywide Infant Feeding Pathway if the family requires support.

Ensure a total feed volume of 150 mg/kg body weight over 24 hours (6-8 times a day)

  • 1-2 week trial of smaller, more frequent feeds (ensuring that the total daily volume of feeds remains the same)


If not effective

  • 1–2 week trial of feed thickeners or pre thicken feeds.These are available to purchase over the counter at a similar price to standard formula.

 

If not effective

  • Revert to normal feeds and offer a 1–2 week trial of Gaviscon® Infant
  • If symptoms improve after a 1–2 week, continue
  • Stop/review treatment at regular intervals (eg every 2 weeks)      

 

If still symptomatic despite regular Infant Gaviscon

  • 4-week trial of proton pump inhibitors (PPIs) or ranitidine, if improvement continue with regular breaks/reviews

 

Review after 1 month:

If symptoms still persist despite the above interventions refer to a paediatrician or paediatric gastroenterologist

Over the counter anti-reflux formula can be purchased at a similar price to standard forumla and the GP should not routinely prescribe; advise to use anti-reflux formula with appropriate safety netting (advice on what to do if symptoms do not improve) may be all that is needed and parents should be asked to purchase the quanitity required.

Recommend over the counter anti-reflux formula such as Cow and Gate®, Aptamil® anti-reflux, Enfamil AR® and SMA Stay Down®.

  • Enfamil AR® and SMA Staydown® are indicated for a maximum of 6 months and a normal teat can be used
  • Over the counter (OTC) thickened formulae contain carob gum. This produces a thickened formula and will require the use of a large hole (fast-flow) teat
  • Thickening formulae react with stomach acids, thickening in the stomach rather than the bottle so there is no need to use a large hole (fast flow) teat
  • SMA Stay Down® contains cornstarch
  • Enfamil AR® contains rice starch
  • Alert parents/carers to the need to make up thickening formulae with fridge cooled pre-boiled water (see tin for full instructions)
  • If prescribed, pre-thickened formulas or feed thickeners must be endorsed by the Advisory Committee on Borderline Substances (ACBS).
  • Seek prescribing advice if needed in primary care from the Medicines Optimisation Team
  • Seek prescribing advice if needed in secondary care from the local Hospital Medicines Information Centre

DO NOT

  • Do not advise Nutriprem 2 Liquid® or SMA Gold Prem 2 Liquid® unless there is a clinical need.
  • Do not advise thickening formulae (SMA Staydown®, Enfamil AR®) with separate thickeners or in conjunction with medication such as antacids, ranitidine, or proton pump inhibitors, since the formulae need stomach acids to thicken and reduce reflux.
  • Do not advise omeprazole suspension (unlicensed) because it is the only proton pump inhibitor liquid preparation available and needs to be ordered by the pharmacy from a specials laboratory. Therefore, very expensive. (Dispersible omeprazole tablets may be a suitable alternative depending on dose required)
  • Do not suggest Infant Gaviscon® more than 6 times in 24 hours or where the infant has diarrhoea or a fever, due to its sodium content. N.B. Each half of the dual sachet of Infant Gaviscon® is identified as ‘one dose’. To avoid errors, prescribe with directions in terms of ‘dose’.
  • Do not advise domperidon, metoclopramide or erythromycin to manage gastro-oesophageal reflux (GOR) or gastro-oesophageal reflux disease (GORD) in infants, children and young people without specilasit paediatric advice.

  • Try and keep baby as upright as possible during and after feeds
  • Infants with reflux often nurse well when sleepy or asleep as they are relaxed
  • Elevating the head of the cot safely (putting something underneath legs of cot) can help

~Review after one month

When to Refer

If symptoms do not improve one month after commencing treatment refer to a paediatrician for further investigations since cow's milk protein allergy (CMPA) can co-exist with GORD and treatment as for CMPA may be required.

  • An uncertain diagnosis or red flag symptoms which suggest a more serious condition
  • Persistent, faltering growth associated with regurgitation
  • Unexplained distress in children with communication difficulties
  • Not responding to medical therapy
  • Feeding aversion and a history of regurgitation
  • Unexplained iron deficiency anaemia
  • No improvement in regurgitation or symptoms persisting after 1 year of age
  • Suspected Sandifer's syndrome

  • Suspected recurrent aspiration pneumonia
  • Unexplained apnoeas
  • Unexplained epileptic seizure-like events
Ongoing Primary Care
  • Infants with GORD will need regular review to check growth and symptoms.
  • Since GORD will usually resolve spontaneously between 12-15 months, cessation of treatment can be trialled from 12 months. 
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