Introduce yourself to the parent(s) including your name and role.
Confirm the child’s name and date of birth.
Ask about the ideas, concerns and expectations of the parent(s).
Determine the parent(s) priorknowledge of GORD.
“Hello, I’m one of the student doctors working with the practice today. I’ve been asked to come and speak with you, is that okay? Can I just confirm your baby’s name, date of birth and who you are?”
“What are your thoughts about what’s been going on?”
“Was there anything you were concerned about?”
“What were you hoping we’d do today?”
“What do you know about reflux?”
Begin by reassuring the parents that GORD is common in infants (40% are affected) and that there are several treatments available to manage the condition. Explain that in most cases GORD will resolve spontaneously as the child grows.
“First of all try not to worry, reflux is common in infants and in most cases, it will resolve on its own as the child grows. In the meantime, we have several different medications that can help manage the condition.”
Explain the aetiology of GORD whilst avoiding the use of medical jargon wherever possible.
Children under 1 year of age
The oesophageal sphincter is not fully developed in children less than 1-year-old, allowing stomach contents to reflux easily. In addition, because children at this age spend most of their time lying flat, it is much easier for stomach contents to reflux into the oesophagus. Children less than 1 also have a relatively short oesophagus meaning stomach contents can reflux up into the mouth more easily as there is less distance to travel. Reflux is also significantly more common in premature infants and children with cerebral palsy or Down’s syndrome.
Children older than 1 year of age
By the time infants are 1-year-old, GORD will have spontaneously resolved in approximately 90% of cases. Spontaneous resolution occurs for several reasons including strengthing of the lower oesophageal sphincter, spending more time upright and the transition to a diet of solid food.
“When you swallow, food goes down the food pipe, known as the oesophagus, into the stomach. At the bottom of the food pipe, there is a ring of muscle which opens and closes to let food into the stomach. In young babies, this muscle is not fully developed and sometimes may not completely close, which means milk can easily move from the stomach back up into the food pipe and mouth. Babies also spend a lot of time lying flat, which also makes it easier for milk to travel from the stomach back into the food pipe and mouth.”
“By the age of 1, reflux will have resolved in approximately 90% of infants. This spontaneous resolution occurs because the ring of muscle above the stomach becomes increasingly stronger, preventing the backflow of milk into the food pipe. After the age of 1, children also typically spend more time upright and eat a diet that consists of solids, both of which reduce the likelihood of reflux occurring.”
Management of GORD in primary care
Infants with GORD typically experience frequent regurgitation and associated distress during these episodes.
Management of GORD in breastfed infants:
Prescribe a 1-2 week trial of alginate therapy (e.g. Gaviscon® Infant) and if symptoms improve, periodically stop treatment (e.g. every 2 weeks) to see if symptoms have improved and if it is possible to stop treatment completely.
Management of GORD in formula-fed infants:
Reduce the volume of feeds if they are excessive for the child’s weight (a total feed volume of 150mL/kg body weight over 24 hours is recommended).
Offer a 1-2 week trial of smaller, more frequent feeds whilst maintaining an appropriate total daily amount of milk.
Offer a 1-2 week trial of feed thickeners.
If the previous steps are unsuccessful, stop the thickener and offer a 1-2 week trial of alginate therapy. If symptoms improve after the trial continue with the treatment and suggest stopping the treatment at regular intervals to see if symptoms have improved (with the aim of weaning of treatment).
Management of infants unresponsive to first-line treatments
If first-line treatments failto control symptoms in either breastfed or formula-fed infants:
Consider a 4 week trial of a proton pump inhibitor (e.g. omeprazole) or a histamine-2 receptor antagonist (e.g. ranitidine) to reduce stomach acid production.
If symptoms persist despite all of the above steps, refer to paediatrics.
Some clinical features which indicate a need for paediatric referral include:
Persistent faltering growth associated with regurgitation
Failure to respond to initial management options (as discussed below)
Feeding aversion and history of regurgitation
Iron deficiency anaemia
No improvement in regurgitation after 1 year of age
Suspected aspiration pneumonia
Clinical features that indicate a need for same-day hospital admission:
“The first thing I’d suggest we try is a 1-2 week trial of smaller, more frequent feeds of around 6-8 times a day, still making sure that your baby gets an appropriate total amount of milk over a 24 hour period.”
“If we don’t see any improvement, we could try a 1-2 week trial of adding a thickening agent to the formula milk which makes the milk heavier and more likely to stay in the stomach.”
“If we still don’t see much of an improvement, we could consider a 1-2 week trial of Gaviscon which is a medication that neutralises stomach acid.”
“If the Gaviscon medication doesn’t seem to be improving symptoms, we could consider a 4 week trial of a medication that reduces the amount of acid the stomach produces.”
“If despite all of these options, the reflux was still troublesome, I would refer you to a paediatrician to consider some further tests and treatment.”
“Although in most cases reflux resolves on its own over time, it’s important to be aware of some rare but serious symptoms that, if present, would require your baby to be reviewed urgently in hospital. These symptoms include your baby’s stools turning black or the presence of blood in their vomit. If either of these symptoms were to develop, we would need to arrange same-day admission to the hospital.”
Closing the consultation
Summarise the keypoints from the consultation:
“So, just to summarise, your baby is currently suffering from reflux, which is very common for an infant their age. Reflux involves the backflow of stomach contents into the food pipe up towards the mouth. Reflux spontaneously resolves in over 90% of infants by the time they are 1-year-old and in the meantime, we have several treatments that can improve symptoms. In some cases, we may need to refer your baby to a paediatrician for further assessment if the treatments don’t control the symptoms or if the reflux continues after they are 1-year old. Rarely, reflux can result in bleeding within the stomach and food pipe, causing blood to be present in the vomit and the stools to become very black. This can be very serious and would require urgent hospital admission.”
Check parental understanding and provide them with an opportunity to askquestions:
“Does everything I’ve said so far make sense?”
“Do you have any questions for me?”
Provide the parent(s) with details of resources where they can learn more (e.g. leaflet, website).
Provide some safety net advice: “This condition is very common, and as your baby is still growing well it is not something to be too concerned about. However if things don’t seem to be settling and you are concerned, please don’t hesitate to call us for another review.”
Arrange follow-up: “I would like to see you again in a few weeks to see how you and baby are doing with some of the changes we have discussed. In the meantime, if you have any concerns or further questions, please feel free to contact me or the GP practice.”
Thank the parents for their time.
Dispose of PPE appropriately and wash your hands.
NICE CKS. Management of gastro-oesophageal reflux disease in children. Published February 2019. Available from: [LINK].