Gastro-oesophageal reflux disease in children and young people: diagnosis and management

Introduction

Gastro‑oesophageal reflux (GOR) is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, gastro‑oesophageal reflux disease (GORD) occurs when the effect of GOR leads to symptoms severe enough to merit medical treatment. GOR is more common in infants than in older children and young people, and it is noticeable by the effortless regurgitation of feeds in young babies.

In clinical practice, it is difficult to differentiate between GOR and GORD, and the terms are used interchangeably by health professionals and families alike. There is no simple, reliable and accurate diagnostic test to confirm whether the condition is GOR or GORD, and this in turn affects research and clinical decisions. Furthermore, the term GORD covers a number of specific conditions that have different effects and present in different ways. This makes it difficult to identify the person who genuinely has GORD, and to estimate the real prevalence and burden of the problem. Nevertheless, regardless of the definition used, GORD affects many children and families in the UK, who commonly seek medical advice and as a result, it constitutes a health burden for the NHS.

Generally, experts suggest that groups of children most affected by GORD are otherwise healthy infants, children with identifiable risk factors, and pubescent young people who acquire the problem in the same way as adults. The 2 other specific populations of children affected by GORD are premature infants and children with complex, severe neurodisabilities. In the latter group, the diagnosis is complicated further by a tendency to confuse vomiting with or without gut dysmotility with severe GORD. In addition, for a child with neurodisabilities, a diagnosis of GORD often fails to recognise a number of distinct problems that may coexist and combine to produce a very complicated feeding problem in an individual with already very complex health needs. For example, a child with severe cerebral palsy may be dependent on enteral tube feeding, have severe chronic vomiting, be constipated, have marked kyphoscoliosis, possess a poor swallow mechanism and be unable to safely protect their airway resulting in a risk of regular aspiration pneumonia.

This guideline focuses on signs and symptoms and interventions for GORD. Commonly observed events, such as infant regurgitation, are covered as well as much rarer but potentially more serious problems, such as apnoea. Where appropriate, clear recommendations are given as to when and how reassurance should be offered. The guideline also advises healthcare professionals about when to think about investigations, and what treatments to offer. Finally, it is emphasised that other, and on occasion more serious, conditions that need different management can be confused with some of the relatively common manifestations of GOR or GORD. These warning signs are defined under the headings of 'red flags' along with recommended initial actions.