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

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

  • Complications are most common in children with chronic lung disease and neurologic impairment.

Gastroesophageal reflux (GER) is the most common esophageal disorder in children of all ages and is 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). Most of these episodes are short-lived and asymptomatic. Gastroesophageal reflux disease (GERD) is defined as reflux associated with bothersome symptoms and complications.2–4 While the pathophysiology of GER in infants, children, and adults is similar, the symptoms and clinical presentations can be quite different (Table 73-1).

TABLE 73-1Common Symptoms of Gastroesophageal Reflux


GER is common in neonates, occurring in more than 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 a 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. Only 5% to 10% of infants still display symptoms of regurgitation after this time.3–5


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.

A small number of infants will develop complications of reflux and progress to GERD. Common infantile symptoms of GERD include regurgitation and vomiting, sleep disturbances, irritability, feeding difficulties and/or refusal, and failure to thrive.5–8 Most affected infants will display one or more of these symptoms. GERD appears to be less common in breastfed infants than in those that are formula-fed.8 In addition, preterm infants have an increased risk of developing GERD, especially those with bronchopulmonary dysplasia.6

Infants with severe GERD 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.5,9 Excessive crying and arching are caused by painful reflux episodes, and typically occur during or shortly after feeding when ...

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