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  4. Gastro-Oesophageal Reflux Disease (GORD) in Children

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

GORGastro-oesophageal reflux:
  • Passage of gastric content into the oesophagus
  • Common physiological event
  • Often asymptomatic and associated with overt regurgitation (visible regurgitation of feeds)

GORDGastro-oesophageal reflux disease:
  • GORGastro-oesophageal reflux that causes symptoms (e.g. discomfort or pain)

  • 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)

Possible clinical features:
  • Heart burn / retrosternal pain / epigastric pain
  • Feeding difficulties (e.g. refusing to feed, gagging, choking, regurgitation)
  • Hoarseness
  • Cough
  • Faltering growth
 

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
 

Possible complications:
  • Reflux oesophagitis
  • Aspiration pneumonia
  • Otitis media
  • Dental erosion

Diagnosis Guidelines

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:
  • Haematemesis
  • Melaena
  • Dysphagia
  • No improvement after 1 y/o
  • Persistent faltering growth
  • Symptoms requiring medical therapy / refractory to medical therapy
  • Unexplained iron deficiency anaemia
Upper GI contrast study To exclude anatomical abnormalities

Consider if:
  • Billious vomiting
  • Dysphagia
Oesophageal pH study Gold standard test to confirm GOR

Consider if there are unexplained complications of GOR:
  • Recurrent aspiration pneumonia
  • Unexplained apnoeas
  • Unexplained non-epileptic seizure-like events
  • Unexplained upper airway inflammation
  • Dental erosion associated with neurodisability
  • Frequent otitis media

 

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

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

Always attempt general / conservative management first, and only proceed to pharmacological management if these fail.
 

Carry out a breastfeeding assessment and advice

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)

1st line: alginate therapy (trial of 1-2 weeks)

Do not offer PPIProton pump inhibitor or H2 receptor antagonist to treat isolated regurgitation

Consider 4-week trial of PPIProton pump inhibitor 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 options include:
  • Enteral feeding (esp. in faltering growth)
  • Surgery - fundoplication (last resort)
    • Offer upper GI endoscopy and consider other investigations before considering fundoplication

References

Author: Adams Lau
Reviewer:
Last edited: 25/08/25