Gastro-Oesophageal Reflux Disease (GORD)

Whilst these guidelines advise on the appropriate choice of specialist infant formula, breast milk remains the optimal choice for infants. This should be promoted and encouraged where it is clinically safe to do so.

Symptoms

GORD refers to the effortless regurgitation of feeds which leads to troublesome symptoms and/or complications.

Refer to NICE guideline NG1 Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people for further information on signs and symptoms.

GORD is very common and usually begins before the infant is 8 weeks old. In the vast majority, regurgitation will spontaneously improve between 6 and 12 to18 months of age.  If the onset of regurgitation is after the age of 6 months, or if symptoms persist beyond the age of 12 months, other diagnoses should be considered.

‘Red flag’ symptoms and signs that suggest disorders other than GORD:

  • General Symptoms e.g. weight loss, lethargy, fever, excessive irritability or pain, dysuria, the onset of regurgitation or vomiting over 6 months of age or increasing or persisting over 12 to 18 months of age.
  • Neurological symptoms e.g. bulging fontanel or rapidly increasing head circumference, hydrocephalus, seizures, macro or microcephaly.
  • Gastrointestinal symptoms e.g. persistent forceful vomiting, nocturnal vomiting, bilious vomiting, intestinal atresia or mid-gut volvulus, hematemesis, rectal bleeding, abdominal distension, chronic diarrhoea.
  • Cow’s Milk Protein Allergy (CMPA) symptoms e.g. blood in stool, chronic diarrhoea, infants and children with, or at high risk of atopy.

Treatment

Breast fed infants:

  • Breastfeeding should continue. A breastfeeding assessment by a trained professional may be beneficial, see introduction for referral details.

Formula fed infants:

  • For formula fed infants, the frequency and the volume of feedings should be checked and adapted according to age because overfeeding is a risk factor for GORD and regurgitation. Formula feeds should be offered and spread over 6 to 7 feeds and an appropriate total volume should be advised (150ml/kg/day up to 6 months of age).
  • If no improvement: thicken feeds. Trial a commercially-prepared thickened formula for 2 weeks (to be bought over the counter – see list below).

Refer to NICE guideline NG1 for further steps on the treatment and or management of GORD.

Choice of Formula

Thickened Formula (to be bought over the counter)

Aptamil® Anti-Reflux*

Birth to 12 months. Contains carob bean gum, thickens on mixing.

Cow and Gate® Anti-Reflux*

Birth to 12 months. Contains carob bean gum, thickens on mixing.

SMA® Anti-Reflux*

Birth to 12 months. Contains potato starch, thickens on mixing.

Instant Carobel*

Thickener to be added to regular formula or breast milk. Thickens on mixing.

*A faster flow teat may be required for formulas that thicken on mixing.

Recommendations

  • Parents and guardians can be advised that thickened formula can be continued up to 6 months of age, or until 12 months of age if symptoms return with a non-thickened formula. Trial stopping at intervals to check if still needed.
  • Thickened formula or thickener should NOT be used alongside alginate therapy e.g. Gaviscon Infant.
  • As an alternative to thickened formula, Instant Carobel can be added to regular formula. However a commercially-prepared thickened formula is preferred because the effect of the thickener on the composition of the formula has been taken into account. Instant Carobel can also be added to breastmilk. Instant Carobelmay be recommended by speech and language therapy for dysphagia and can be prescribed in these circumstances; however for the treatment of GORD it should be bought over the counter.
  • Thickened formula should be prepared as per manufacturer instructions on the tin.

References and resources