Chapter 72: Gastroesophageal Reflux

High-Yield Facts

• Gastroesophageal reflux (GER) occurs in two-thirds of normal infants in the first year of life.

• Severe gastroesophageal reflux disease (GERD) may include aspiration pneumonia and acute life-threatening events (ALTEs).

• 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 ages and a frequent reason for visits to the pediatric emergency department.¹ It is a normal physiological event that occurs when gastric contents pass into the esophagus through transient relaxations in the lower esophageal sphincter (LES).² While the pathophysiology of GER in infants, children, and adults is similar, the symptoms and clinical presentation can be quite different. (Table 72-1)

Gastroesophageal Reflux in Infants

GER is common in neonates, occurring in up to 60% of healthy infants by 6 months of age. There are multiple factors that predispose infants to GER including immaturity of the LES, short intra-abdominal esophagus, and primarily liquid diet. Reflux generally disappears by 1 year of age as the LES matures and solid foods become a large part of the diet.^3–5 Only 5% of infants still display symptoms of regurgitation after this timeframe.³

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 feeding but are relatively unaffected by it. They gain weight appropriately and typically “outgrow” their symptoms by 12 months of age.^3,6

A small number of infants will develop complications of reflux, referred to as gastroesophageal reflux disease (GERD). Symptoms of GERD include regurgitation and vomiting, sleep disturbances, irritability, feeding difficulties and/or refusal, and failure to thrive.^3,7,8 Most affected infants will display one or more of these symptoms.

Infants with severe GER may develop Sandifer syndrome (spasmodic torsional dystonia), which is characterized by opisthotonus and irritability. The stereotypic stretching and arching movements may be mistaken for seizure activity.³ Excessive crying and arching are caused by painful reflux episodes, and typically occur during or shortly after feeding when gastric acid enters the esophagus. Many infants with this condition will exhibit failure to thrive.

GER may also induce respiratory symptoms in infants including chronic cough, bronchospasm, stridor, and wheezing. In severe cases, aspiration pneumonia may occur. Reflux in infants may also manifest as an acute life-threatening event (ALTE) with respiratory distress and cyanosis.^3...