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Gastro-oesophageal reflux and Gastro-oesophageal reflux disease in infants: Advice for Referrers

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The following is based on the NICE guidelines

Gastro-oesophageal reflux (GOR) is the passage of stomach contents into the oesophagus and a normal physiological process in infants. It is common in young infants who have a liquid diet, spend much of their time lying down, and do not have a fully developed oesophageal sphincter. It usually begins before 8 weeks of age, and 5% of infants will have 6 or more episodes per day. GOR does not need investigation or treatment, and is managed by advising and reassuring parents.

Gastro-oesophageal reflux disease (GORD) occurs in a small proportion of infants and is when GOR is associated with distress or complications. There is no reliable test to distinguish between GOR and GORD. GORD may be present if an infant has obvious distress during and after feeds, starts to refuse feeds (food aversion), coughs or chokes with feeds, develops a hoarse voice, or adopts unusual positions whilst feeding. Most infants with GORD can be managed in primary care.

Red Flags

The following are red flags and infants with these signs/symptoms should be referred to be seen acutely – phone the GP triage line:

  • Large vomits with every feed (to rule out pyloric stenosis)
  • Bile stained vomit/abdominal distension (to rule out a surgical cause)
  • Melena or haematemesis (to rule out surgical cause) – note that if a breastfeeding mother has a cracked/bleeding nipple this may be the cause of blood in vomit
  • Recurrent choking and coughing with feeds (may need ENT assessment)
  • Apnoeic episodes with feeding
  • Episode of pneumonia (suggests severe GORD with aspiration)
Who to Refer?
  • Infants with red flag symptoms (see above)

  • Children with faltering growth with overt regurgitation could be referred for a clinic appointment if they are otherwise well. Please see below for details on referring infants with GORD to a general paediatric clinic

Please include the following points from the history in the clinic referral letter
  1. How is the infant fed? Formula or breast?
  2. If breastfed – how is breastfeeding going? If there are difficulties with breastfeeding, has the mother been signposted to breastfeeding support and/or the Infant Feeding Advisors?
  3. If formula fed – what volumes is the infant taking and are these appropriate for weight? (Aim for 150mls/kg/24 hours in a thriving infant). If the infant is receiving a larger volume of milk and is vomiting, please give advice
  4. How is the infant growing?
  5. Any red flags (see above)?
  6. Social circumstances – support for mother, who is at home?
  7. What has already been tried?
Please include the following points from the clinical examination in the referral letter
  1. General examination findings – does the infant look well?
  2. Growth – is the infant thriving?
  3. Any red flag signs – please see above
Suggestions for management whilst waiting for outpatient appointment

For GOR: these infants do not need to be referred to a clinic. Provide the parents with information about GOR and support. If the infant is formula fed and being overfed, provide suggestions on appropriate amounts of milk and suggest the infant is held upright after feeds.

For GORD in formula fed infants:

  • As above, provide advice on appropriate feed volumes and holding infants upright after feeds.
  • Prescribe Carobel to thicken feeds
  • If symptoms do not settle with Carobel, stop the Carobel and suggest Gaviscon (note – Gaviscon and Carobel should not be given together)
  • If remains symptomatic offer a 4 week trial of Omeprazole (1-3 mg per kg per day). Prescribe the MUPS preparation with instructions on how to dissolve and administer these 

For GORD in breastfed infants:

  • Support the mother to continue with breastfeeding on demand; signpost to support where appropriate 
  • Gaviscon may be tried, but needs to be given as a paste which can be tricky in breastfed infants who are already distressed during feeds (mix 1 sachet with 5mls of cooled boiled water to form a paste; then add 10mls of water and mix; give part way through the feed)
  • If remains symptomatic offer a trial of Omeprazole (1-3 mg per kg per day). Prescribe the MUPS preparation with instructions on how to dissolve and administer these 

Note: One of the side-effects of Gaviscon is constipation. Carobel does not generally cause constipation.

Useful resources for parents whilst waiting for outpatient appointment

NHS information leaflet on GOR

RHC Parent Information on Reflux

RHC Omeprazole for children parent information leaflet with guidance on preparing and administering MUPS.

Useful resources and references for health professionals

NICE guidelines on management of GORD in children aged 0-24 months
Scenario: Management | Management | GORD in children | CKS | NICE

Editorial Information

Last reviewed: 24 August 2022

Next review: 31 August 2025

Author(s): Ruth M Bland, Consultant Medical Paediatrics