Chapter 394

Gastroesophageal reflux (GER) is the spontaneous passage of gastric contents into the esophagus. It is a normal physiologic process that occurs throughout the day in healthy infants, children, and adults. In infants, refluxed material often is expelled from the mouth, a benign process known as “spitting-up,” “spilling,” or “posseting.” Gastroesophageal reflux disease (GERD) results from failure of the normal protective mechanisms that prevent damage to the aerodigestive tract following GER and is purported to manifest with a variety of symptoms and signs, shown in Figure 394-1. For almost all of these symptoms and signs, alternative etiologies must be considered prior to concluding that GERD is causative. This is particularly true in the infant and younger child because it is difficult to differentiate in young patients between GER and vomiting, and their symptoms are nonspecific.

###### Figure 394-1.

Classification schema for gastroesophageal reflux disease.

### Epidemiology

Half of all infants between 0 and 3 months of age and two thirds of 4- to 6-month-old infants regurgitate at least once per day. The prevalence of regurgitation decreases dramatically after 8 months of age1,2 (eFig. 394.1). Typically, these infants are otherwise thriving and outgrow this problem by 18 to 24 months of age. Infants with GER are not at increased risk of ear, sinus, upper respiratory infections, or wheezing compared to a control population, but there may be a higher likelihood of feeding refusal than was found among the control infants.1 Gender, breast-feeding, and environmental tobacco smoke exposure are not significant factors related to infant regurgitation.2 In children between 3 to 9 years of age, symptoms of heartburn are reported in 2% to 5 %, epigastric pain in 7%, and regurgitation in 2% to 4 %.2,3,4 About 5% of adolescents report symptoms of heartburn, epigastric pain, or regurgitation.3 Follow-up studies of children and adolescents with GERD suggest that chronic symptoms may persist and require continued management through adulthood.4,5 Hiatal hernia (Fig. 394-2),6 obesity,7 and family history8,9 all may increase the risk of GERD. In a small number of infants and children, GER may cause chronic symptoms, but the true GER-related incidence for each of these is uncertain.

###### eFigure 394.1

Natural history of gastroesophageal reflux disease in children up to age 2 years old: infant “spilling” (vomiting/regurgitating).

(Data from Martin AJ, Pratt N, Kennedy JD, et al. Natural history and familial relationships of infant spilling to 9 years of age. Pediatrics. 2002;109(6):1061-1067.)

###### Figure 394-2.

Endoscopic photograph of hiatal hernia.

(Source: Reprinted with permission from Gastrolab, Vasa, Finland: http://www.gastrolab.net.)

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