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Key Features

Essentials of Diagnosis

  • Gastroesophageal reflux (GER): Frequent postprandial regurgitation, ranging from effortless to forceful

  • Gastroesophageal reflux disease (GERD)

    • Regurgitation into the mouth

    • Heartburn

    • Dysphagia

  • Extraesophageal manifestations of GERD

    • Implicated in the pathogenesis of several disorders unrelated to esophageal dysfunction

    • Has been linked to the occurrence of apnea or apparent life-threatening events in infants

  • Warning signs that warrant further investigation in the infant with recurrent vomiting

    • Bile-stained emesis (a warning sign for intestinal obstruction)

    • Gastrointestinal (GI) bleeding

    • Onset of vomiting after 6 months

    • Failure to thrive

    • Diarrhea

    • Fever

    • Hepatosplenomegaly

    • Abdominal tenderness or distention

    • Neurologic changes

General Considerations

  • GER

    • Refers to uncomplicated recurrent spitting and vomiting in healthy infants that resolves spontaneously

    • Factors promoting reflux in infants include

      • Small stomach capacity

      • Frequent large-volume feedings

      • Short esophageal length

      • Supine positioning

      • Slow swallowing response to the flow of refluxed material up the esophagus

    • Infants' individual responses to the stimulus of reflux, particularly the maturity of their self-settling skills, are important factors determining the severity of reflux-related symptoms

  • GERD is present when reflux causes secondary symptoms or complications

  • Esophageal manifestations of GERD include symptoms (heartburn, regurgitation) and mucosal complications (esophagitis, stricture, Barrett esophagus) primarily related to acid exposure in the upper GI tract, primarily the esophagus itself

  • Extraesophageal manifestations of GERD include a myriad of clinical disorders that may be linked to reflux, including upper and lower airway symptoms and findings, as well as dental erosions

Clinical Findings

  • GER in infants

    • Frequent postprandial regurgitation, ranging from effortless to forceful

    • Reflux of gastric contents into the esophagus occurs during spontaneous relaxations of the lower esophageal sphincter that are unaccompanied by swallowing

    • GERD is indicated when following symptoms develop

      • Failure to thrive

      • Food refusal

      • Pain behavior

      • GI bleeding

      • Upper or lower airway-associated respiratory symptoms

      • Sandifer syndrome

  • GERD in older children

    • Regurgitation into the mouth

    • Heartburn

    • Dysphagia

    • Children with asthma, cystic fibrosis, developmental handicaps, hiatal hernia, and repaired tracheoesophageal fistula are at increased risk for GERD and esophagitis

  • Extraesophageal manifestations of GERD

    • While proof of cause-and-effect is challenging, the following have been linked to GERD

      • Hoarseness

      • Sinusitis

      • Laryngeal erythema

      • Edema

      • Asthma

      • Recurrent pneumonia

      • Recurrent cough

      • Dental erosions

      • Sandifer syndrome


  • An upper GI series

    • Should be considered when anatomic etiologies of recurrent vomiting are considered

    • However, should not be considered to be a test for GERD

  • Esophagoscopy and mucosal biopsies are useful to evaluate for

    • Mucosal injury secondary to GERD (Barrett esophagus, stricture, erosive esophagitis)

    • Nonreflux diagnoses that present with reflux-like symptoms, including eosinophilic esophagitis

  • Endoscopic evaluation is not requisite for the evaluation of all infants and children with suspected GERD.

  • Intraluminal esophageal pH monitoring (pH probe) and combined multiple intraluminal impedance and pH monitoring (pH impedance probe) are indicated to

    • Quantify reflux,

    • Evaluate for objective evidence of symptom associations with regards to atypical reflux presentations

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