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  • Gastroesophageal reflux (GER) occurs in two thirds of normal infants for the first year of life.
  • Symptomatic GER (GERD) in infants includes excessive crying, irritability, arching of back during feeds, sleep disturbance, and poor weight gain.
  • Severe GERD may include aspiration pneumonia, and acute life-threatening events.
  • Treatment for mild GERD includes smaller, more frequent feedings, thickened formula with cereal, and elevating the head of the crib; for severe cases, H2 receptor antagonists or proton pump inhibitors may be considered.
  • Esophageal pH probe, intraluminal impedance monitoring, upper GI imaging, and endoscopy may be helpful in selected cases of GERD for defining cause and recognizing complications.
  • Complications are most common in children with neurologic impairment and swallowing dysfunction.


Gastroesophageal reflux (GER) is the most common esophageal disorder in children of all ages1 and a frequent reason for visits to the pediatric emergency department. It occurs when gastric contents pass into the esophagus through transient relaxations in the lower esophageal sphincter. While the pathophysiology of GER in infants, children, and adults is similar, the symptoms and clinical presentation can be quite different (Table 73–1).

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Table 73-1. Common Symptoms of Gastroesophageal Reflux

GER is nearly universal in infants, occurring in up to 67% of healthy, thriving infants by 4 to 5 months of age.2 There are multiple factors that predispose infants to GER including immaturity of the esophagus and lower esophageal sphincter, incomplete propagation of esophageal contractions, short length of the abdominal esophagus, and liquid diet.3,4


Clinical Presentation of GER in Infants


The great majority of infants with physiologic reflux are “happy spitters.” These infants typically regurgitate small volumes of breast milk or formula after feedings but are relatively unaffected by it. They gain weight appropriately and typically “outgrow” their symptoms by 12 months of age as esophageal and gastric motility mature.2


A small number of infants will develop complications of reflux, referred to as gastroesophageal reflux disease (GERD). Infants with GERD may present with excessive crying, irritability, arching, sleep disturbance, feeding aversion, and poor weight gain.5,6 Excessive crying and arching typically occur during or shortly after feeds when gastric acid enters the esophagus and causes discomfort. These stereotypic stretching and arching movements can be mistaken for seizures in a condition known as Sandifer syndrome. Over time, infants with severe symptoms may develop an aversion to feeding and failure to thrive.


GER may induce respiratory symptoms in infants including chronic cough, stridor, and wheezing. In severe cases, aspiration pneumonia may occur. Reflux in infants may also manifest as an acute ...

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