The main challenge in evaluating infants with symptoms of reflux is distinguishing reflux from true vomiting. Reflux typically occurs during or shortly after feeding and does not involve forceful muscle contraction. Vomiting occurs when stomach contents are forcefully expelled into the esophagus and out of the mouth by contractions of the abdominal and chest wall muscles. While this distinction can be difficult in infants, vomiting should prompt consideration of other diagnoses. Other symptoms that may require further investigation and/or referral to a specialist include bilious emesis, GI bleed, weight loss, diarrhea, abdominal distention, dysphagia, splenomegaly or hepatomegaly, and coexisting seizure disorder.2 Alternative diagnoses may include milk protein allergy, food allergy, eosinophilic esophagitis, stricture, esophageal web, hiatal hernia, pyloric stenosis (Fig. 72-1), intestinal obstruction (malrotation/volvulus), foreign-body ingestion, infection, inborn errors of metabolism, and increased intracranial pressure (Table 72-2).