NICE has published nine quality standards covering gastro-oesophageal reflux in children and young people.
NICE notes that gastro-oesophageal reflux “is a normal physiological process” that usually occurs after eating, is more common in infants than in older children, and presents as “effortless regurgitation of feeds”. In gastro-oesophageal reflux disease (GORD), severe reflux symptoms need treatment.
One quality standard remarks that some symptoms “commonly mistaken” for GORD may be ‘red flags’ for other problems and require specialist referral or further investigation. For example, intestinal obstruction may cause bile-stained (green or yellow-green) vomit. Blood in stool could indicate, for example, bacterial gastroenteritis or cows’ milk allergy. Chronic diarrhoea might also suggest cows’ milk allergy.
Another quality standard comments that infants, children and young people should not receive domperidone, metoclopramide or erythromycin (used as a prokinetic) to manage gastro-oesophageal reflux or GORD without advice from a paediatrician. This reflects the risks, such as neurological and cardiac side-effects.
In addition, the standards say that “there is no evidence” that acid-suppressing drugs, including proton pump inhibitors or H2 receptor antagonists, reduce regurgitation in infants and children. NICE concludes that “unnecessary use should be avoided” and should not be prescribed “if visible regurgitation is an isolated symptom”.
NICE suggest that first-line management includes feeding assessment and advice for breast-fed infants or a stepped-care approach for formula-fed infants. Alginate can be tried if first-line management is unsuccessful. But thickened formula feeds should be stopped before using alginates.