National Collaborating Centre for Women’s and Children’s Health Final version Gastro-oesophageal reflux disease in children and young people Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people NICE Guideline 1 Methods, evidence and recommendations January 2015 Final version Commissioned by the National Institute for Health and Care Excellence Gastro-oesophageal reflux disease in children and young people Contents Disclaimer Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer. Copyright National Collaborating Centre for Women’s and Children’s Health 2015 Funding National Institute for Health and Care Excellence 2015 National Collaborating Centre for Women’s and Children’s Health 2015 Gastro-oesophageal reflux disease in children and young people Contents Contents Guideline summary ............................................................................................................. 8 1 Introduction ................................................................................................................ 10 1.1 Aim of the guideline ............................................................................................. 11 1.2 Definitions used in this guideline ......................................................................... 11 1.2.1 Infants, children and young people........................................................... 11 1.2.2 Gastro-oesophageal reflux (GOR)............................................................ 11 1.2.3 Gastro-oesophageal reflux disease (GORD) ............................................ 11 1.2.4 Marked distress ........................................................................................ 11 1.2.5 Occult reflux ............................................................................................. 11 1.2.6 Overt regurgitation ................................................................................... 11 1.2.7 Specialist ................................................................................................. 12 1.3 Areas within the remit of the guideline ................................................................. 12 1.4 Areas outside the remit of the guideline ............................................................... 12 1.5 For whom is this guideline intended..................................................................... 13 1.6 Who has developed the guideline ........................................................................ 13 1.7 Related NICE guidelines ..................................................................................... 13 1.7.1 Published guidelines ................................................................................ 13 2 Guideline development methodology ....................................................................... 15 2.1 Developing review questions and protocols and identifying evidence .................. 15 2.2 Reviewing and synthesising evidence ................................................................. 15 2.3 Outcome measures ............................................................................................. 17 2.4 Incorporating health economics ........................................................................... 17 2.5 Evidence to recommendations ............................................................................ 18 2.6 Stakeholder involvement ..................................................................................... 18 3 Recommendations and care pathway ....................................................................... 19 3.1 Key priorities for implementation ......................................................................... 19 3.2 Recommendations .............................................................................................. 21 3.3 Research recommendations ................................................................................ 28 3.4 Care pathway ...................................................................................................... 28 4 Diagnosing and investigating GORD ........................................................................ 35 4.1 Natural course of overt regurgitation .................................................................... 35 4.1.1 Review questions ..................................................................................... 35 4.1.2 Description of included studies ................................................................. 35 4.1.3 Evidence profile ....................................................................................... 36 4.1.4 Evidence statements ................................................................................ 37 4.1.5 Health economics profile .......................................................................... 44 4.1.6 Evidence to recommendations ................................................................. 44 4.1.7 Recommendations ................................................................................... 47 National Collaborating Centre for Women’s and Children’s Health 2015 4 Gastro-oesophageal reflux disease in children and young people Contents 4.1.8 Research recommendations .................................................................... 48 4.2 Signs and symptoms ........................................................................................... 48 4.2.1 Identifying symptoms and signs of GORD ................................................ 48 4.2.2 Distressed behaviour ............................................................................... 51 4.2.3 Apnoea .................................................................................................... 55 4.2.4 Epigastric or chest pain ............................................................................ 59 4.2.5 Hoarseness .............................................................................................. 62 4.2.6 Feeding difficulties ................................................................................... 64 4.2.7 Otitis media .............................................................................................. 68 4.2.8 Lower respiratory tract infection ............................................................... 70 4.2.9 Faltering growth ....................................................................................... 72 4.2.10 Asthma .................................................................................................... 74 4.2.11 Chronic cough .......................................................................................... 76 4.2.12 Dental erosion .......................................................................................... 78 4.2.13 Health economics profile .......................................................................... 80 4.2.14 Evidence to recommendations ................................................................. 80 4.2.15 Recommendations ................................................................................... 86 4.2.16 Research recommendations .................................................................... 88 4.3 Risk factors ......................................................................................................... 88 4.3.1 Review question ....................................................................................... 88 4.3.2 Introduction .............................................................................................. 88 4.3.3 Chronic lung disease................................................................................ 89 4.3.4 Neurodisabilities ....................................................................................... 93 4.3.5 Prematurity .............................................................................................. 96 4.3.6 Surgical or congenital disorders ............................................................... 99 4.3.7 Family history of GORD ......................................................................... 102 4.3.8 Obesity .................................................................................................. 104 4.3.9 Health economics profile ........................................................................ 111 4.3.10 Evidence to recommendations ............................................................... 111 4.3.11 Recommendations ................................................................................. 114 4.3.12 Research recommendations .................................................................. 114 4.4 Indications for investigation and treatment......................................................... 114 4.4.1 Review questions ................................................................................... 114 4.4.2 Description of included studies ............................................................... 114 4.4.3 Evidence profile ..................................................................................... 114 4.4.4 Evidence statements .............................................................................. 115 4.4.5 Health economics profile .......................................................................