Gastro-oesophageal Reflux (NICE CKS 2023)_flashcards
What should be done to reassure parents about gastro-oesophageal reflux (GER) in infants?
It is very common, begins early (< 8 weeks) and may be frequent. It usually becomes less frequent with time. Treatment and investigation are not usually needed.
When should an infant or child with GER be reviewed?
Projectile regurgitation, bile-stained vomit or haematemesis, new concerns (e.g. faltering growth, feeding difficulties), persistent, frequent regurgitation beyond the first year of life.
When is a same day referral necessary for an infant or child with GER?
Haematemesis, melaena, signs of raised ICP (e.g. bulging fontanelle) or dysphagia.
What is the initial management for breastfed infants with GER?
Carry out a breastfeeding assessment. Trial smaller but more frequent feeds. If issue persists despite advice, consider trial of alginate therapy for 1-2 weeks (stop at intervals to check whether the infant has recovered).
What is the initial management for formula-fed infants with GER?
Review feeding history. Reduce feed volumes if excessive for infant’s weight (aim for 150-180 mL/kg/day). FIRST: Offer a trial of smaller, more frequent feeds. SECOND: Offer a trial of thickened formula or anti-regurgitant formula. THIRD: Offer alginate therapy without feed thickeners if the above hasn’t worked (stop at 2-week intervals to see if the infant has recovered). Trials are recommended to last 1-2 weeks.
What positional advice should be given for managing GER?
Advise about upright positioning after feeds and avoiding overfeeding. Prone and left-lateral positioning helps but should be used when awake. Do NOT use positional management in a sleeping infant (they should sleep on their back).
When should pharmacological management be considered for GER?
Consider 2-4-week trial of PPI or histamine antagonist in children who have 1 or more of the following: Unexplained feeding difficulties (refusing feeds, choking), distressed behaviour, faltering growth, no resolution respite 1-2 week trial of alginate therapy. Consider specialist referral if still no resolution.
What are the last resort options for GER if other measures fail?
Enteral feeding (if failure to thrive), Nissen fundoplication (The fundus of the stomach is wrapped around the intra-abdominal oesophagus, abdominal or laparoscopic procedure).
What should be considered if the child fails to respond to GER measures?
If the child fails to respond to these measures, other diagnoses e.g. cow’s milk protein allergy should be considered.
What is the recommended management for inguinal hernia in children?
Surgical repair; timing is based on whether there are complications or not. If there are suspected complications (i.e. strangulation or bowel obstruction): emergency hospital admission. Otherwise: arrange urgent referral to paediatric surgeon, preferably within 2 weeks.
What is the recommended management for umbilical hernia in children?
If small and asymptomatic: Observation until 4-5 years of age. If small, then elective repair at 4-5 years. If large and symptomatic: Elective repair at 2-3 years of age. Large or symptomatic umbilical hernia (> 1.5cm). Intermittent symptoms of incarceration or recurring pain. If hernia incarcerates during observation period: Then should be manually reduced with pressure and surgically repaired at earliest opportunity.
What PACES tips should be given to parents regarding GER diagnosis and management?
Explain the diagnosis (due to immaturity of the gullet leading to food coming back up). Reassure that this is common and usually gets better with time. Breastfeeding: offer assessment → alginate therapy. Formula: review feeding history → smaller, more frequent feeds → thickeners → alginate therapy. Safety net: keep an eye on the vomitus (if it’s blood-stained or green seek medical attention).
