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Referral criteria from primary care - gastro-oesophageal reflux disease (GORD) in infancy

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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In infants, children and young people with vomiting or regurgitation, look out for the 'red flags' in table below, which may suggest disorders other than GOR. Investigate or refer using clinical judgement.

Do not routinely investigate or treat for GOR if an infant or child without overt regurgitation presents with only 1 of the following:

  • unexplained feeding difficulties (for example, refusing to feed, gagging or choking)
  • distressed behaviour
  • faltering growth
  • chronic cough
  • hoarseness
  • a single episode of pneumonia

Do not offer an upper gastrointestinal (GI) contrast study to diagnose or assess the severity of gastrointestinal reflux disease (GORD) in infants, children and young people.

Arrange a specialist hospital assessment for infants, children and young people for a possible upper GI endoscopy with biopsies if there is:

  • haematemesis (blood-stained vomit) not caused by swallowed blood (assessment to take place on the same day if clinically indicated; also see table )
  • melaena (black, foul-smelling stool; assessment to take place on the same day if clinically indicated; also see table )
  • dysphagia (assessment to take place on the same day if clinically indicated)
  • no improvement in regurgitation after 1 year old
  • persistent, faltering growth associated with overt regurgitation
  • unexplained distress in children and young people with communication difficulties
  • retrosternal, epigastric or upper abdominal pain that needs ongoing medical therapy or is refractory to medical therapy
  • feeding aversion and a history of regurgitation
  • unexplained iron-deficiency anaemia
  • a suspected diagnosis of Sandifer's syndrome

'Red flag' symptoms suggesting disorders other than GOR

Symptoms and signs

Possible diagnostic implications

Suggested actions

Gastrointestinal

Frequent, forceful (projectile) vomiting

May suggest hypertrophic pyloric stenosis in infants up to 2 months old

Paediatric surgery referral

Bile-stained (green or yellow-green) vomit

May suggest intestinal obstruction

Paediatric surgery referral

Haematemesis (blood in vomit) with the exception of swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast-fed infants

May suggest an important and potentially serious bleed from the oesophagus, stomach or upper gut

Specialist referral

Onset of regurgitation and/or vomiting after 6 months old or persisting after 1 year old

Late onset suggests a cause other than reflux, for example a urinary tract infection. Persistence suggests an alternative diagnosis

Urine microbiology investigation

Specialist referral

Blood in stool

 

May suggest a variety of conditions, including bacterial gastroenteritis, infant cows' milk protein allergy or an acute surgical condition

Stool microbiology investigation

Specialist referral

Abdominal distension, tenderness or palpable mass

May suggest intestinal obstruction or another acute surgical condition

Paediatric surgery referral

Chronic diarrhoea

May suggest cows' milk protein allergy

Specialist referral

Systemic

Appearing unwell

Fever

May suggest infection

Clinical assessment and urine microbiology investigation

Specialist referral

Dysuria

May suggest urinary tract infection

Clinical assessment and urine microbiology investigation

Specialist referral

Bulging fontanelle

May suggest raised intracranial pressure, for example, due to meningitis

Specialist referral

Rapidly increasing head circumference (more than 1 cm per week)

Persistent morning headache, and vomiting worse in the morning

May suggest raised intracranial pressure, for example, due to hydrocephalus or a brain tumour

Specialist referral

Altered responsiveness, for example, lethargy or irritability

May suggest an illness such as meningitis

Specialist referral

Infants and children with, or at high risk of, atopy

Infants and children with, or at high risk of, atopy

Specialist referral

Perform an urgent (same day) upper GI contrast study for infants with unexplained bile-stained vomiting. Explain to the parents and carers that this is needed to rule out serious disorders such as intestinal obstruction due to mid-gut volvulus.

Consider an upper GI contrast study for children and young people with a history of bile-stained vomiting, particularly if it is persistent or recurrent.

Offer an upper GI contrast study for children and young people with a history of GORD presenting with dysphagia.

Arrange an urgent specialist hospital assessment to take place on the same day for infants younger than 2 months with progressively worsening or forceful vomiting of feeds, to assess them for possible hypertrophic pyloric stenosis.

Reference:


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