Primary Care management of GOR and GORD in children Dr Philippa Edmonds GP Registrar May 2017 Dr Sanjay Suri Consultant Paediatrician Published: 24-Jul-2015 Valid until: 31-Aug-2019 Regurgitation PLUS 1 or more symptoms (GORD)* Distress/feeding difficulties/faltering growth Isolated regurgitation (GOR) GORD in infants (<1yr) GORD in children (1 year and older) 0-19 practitioner (HV1) to manage initially Uncomplicated infantile gastro-oesophageal reflux (<1yr) Conservative management/parental advice/education & reassurance (0-19 practitioner 1) Advise to return if red flags or distress/feeding difficulties/faltering growth. Raise the head of the bed, lie prone or with left side down Trial of Gaviscon for 1-2 weeks Older children: Avoid large meals and late night eating. Dietary modification (avoid caffeine/ chocolate/spicy food & alcohol/smoking – if relevant)   Formula fed Amend feed volumes 3/frequency (0-19 practitioner 1/GP) Conservative management/parental advice/education & reassurance (0-19 practitioner 1/GP) Offer thickened feeds (pre-thickened formula 4/ added thickener5 ) (GP/ 0-19 practitioner ) If ineffective Stop thickened feeds and give trial of Gaviscon Infant added to feed for 1-2 weeks (GP) Consider CMPA (Cow’s Milk Protein Allergy) and refer to Dietitian2 for 2-4 week trial of EHF/AA based (extensively hydrolysed/amino acid based) formula (0-19 practitioner 1/GP)   Breast fed infants Breast feeding assessment and consider referral to breast feeding specialist clinic (0-19 practitioner 1) Conservative management/parental advice/education & reassurance (0-19 practitioner 1) Discussion with GP re trial of Gaviscon Infant after feeds for 1-2 weeks (continue if effective)   Consider Acid suppressing drugs 4 week of a PPI (Omeprazole/Lansoprazole) or H2 receptor antagonist (Ranitidine) (Ranitidine is licensed for children aged >3yrs);Omeprazole licensed for severe ulcerating reflux oesophagitis > 1 year age ; Lansoprazole unlicensed)   Discussion with secondary care regarding further management OR Consider starting acid suppressing drugs 4 week of a PPI (Omeprazole/Lansoprazole) or H2 receptor antagonist (Ranitidine) (Ranitidine is licensed for children aged >3yrs);Omeprazole licensed for severe reflux oesophagitis > 1 year age ;Lansoprazole unlicensed) Red flag symptoms: Projectile /bile stained vomiting/ haematemesis, Blood PR, Abdominal distension Chronic diarrhoea, Systemic symptoms and signs, Dysuria, Signs of raised ICP, Altered responsiveness Weight loss/faltering growth Review and consider referral Careful follow up of interval weight gain and calorie intake. Regular review/have a low threshold for referral as patients with symptoms warranting acid suppressing drugs are those that may have reflux oesophagitis. If symptoms are unresolved or recur consider specialist referral to a Paediatrician   Refer to secondary care – specialist referral to a Paediatrician

Primary Care management of GOR and GORD in children – notes Risk factors for GORD* prematurity, cystic fibrosis, repaired oesophageal atresia/diaphragmatic hernia, obesity, asthma, hiatus hernia, family history of GORD, neurodisability 0-19 practitioner 1 responsibility Conservative management/parental advice; education & reassurance Breast feeding assessment Amend feed volumes/frequency and monitor weight gain Advise to return if red flags When to refer to the dietitian 2 Cows milk protein allergy IgE or non IgE mediated) try a cows milk protein elimination trial for 2-4 weeks Faltering growth (crossing 2 centile lines) Diagnosis and investigation Only investigate/treat if there is overt regurgitation + another symptoms (Feeding difficulties, distressed behaviour, faltering growth, chronic cough, hoarseness or a single episode of pneumonia.). Blood tests aren’t routinely done in primary care. Do a urine dip to rule out infection Feeding volumes 3 0-6 months of age formula requirement 150mls/kg/day. Over 6 months of age and taking weaning foods, minimum of 500ml infant formula required per day. Pre-thickened formulas 4 Thickened formulas are available over the counter to buy e.g. Aptamil Anti reflux, Cow and gate Anti reflux and SMA Staydown.  No need to refer to Dietitian for thickened formulas due to over the counter availability. Thickeners 5 Cow and Gate Instant Carobel can be prescribed by GP for term, bottle fed infants. Directions for thin bottle feed and thick bottle feed are provided on packaging.