referral criteria from primary care - gastro-oesophageal reflux disease (GORD) in infancy
Last reviewed 08/2021
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.
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