Gastroesophageal reflux (GER) is the spontaneous passage of gastric
contents into the esophagus. It is a normal physiologic process that
occurs throughout the day in healthy infants, children, and adults.
In infants, refluxed material often is expelled from the mouth,
a benign process known as “spitting-up,” “spilling,” or “posseting.” Gastroesophageal
reflux disease (GERD) results from failure of the normal protective
mechanisms that prevent damage to the aerodigestive tract following
GER and is purported to manifest with a variety of symptoms and
signs, shown in Figure 394-1. For almost all
of these symptoms and signs, alternative etiologies must be considered
prior to concluding that GERD is causative. This is particularly
true in the infant and younger child because it is difficult to differentiate
in young patients between GER and vomiting, and their symptoms are
Classification schema for gastroesophageal reflux disease.
Half of all infants between 0 and 3 months of age and two thirds
of 4- to 6-month-old infants regurgitate at least once per day.
The prevalence of regurgitation decreases dramatically after 8 months
of age1,2 (eFig. 394.1).
Typically, these infants are otherwise thriving and outgrow this problem
by 18 to 24 months of age. Infants with GER are not at increased
risk of ear, sinus, upper respiratory infections, or wheezing compared
to a control population, but there may be a higher likelihood of
feeding refusal than was found among the control infants.1 Gender,
breast-feeding, and environmental tobacco smoke exposure are not
significant factors related to infant regurgitation.2 In
children between 3 to 9 years of age, symptoms of heartburn are
reported in 2% to 5 %, epigastric pain in 7%,
and regurgitation in 2% to 4 %.2,3,4 About
5% of adolescents report symptoms of heartburn, epigastric pain,
or regurgitation.3 Follow-up studies of children
and adolescents with GERD suggest that chronic symptoms may persist and
require continued management through adulthood.4,5 Hiatal
hernia (Fig. 394-2),6 obesity,7 and
family history8,9 all may increase the risk of GERD.
In a small number of infants and children, GER may cause chronic
symptoms, but the true GER-related incidence for each of these is
Natural history of gastroesophageal reflux disease in
children up to age 2 years old: infant “spilling” (vomiting/regurgitating).
(Data from Martin AJ, Pratt N, Kennedy JD, et
al. Natural history and familial relationships of infant spilling
to 9 years of age. Pediatrics. 2002;109(6):1061-1067.)
Endoscopic photograph of hiatal hernia.
(Source: Reprinted with permission from Gastrolab,
Vasa, Finland: http://www.gastrolab.net.)
A higher prevalence of GERD ...