A primary care approach to

pediatric gastroesophageal reflux

BHANU SUNKU, MD
RONALD V. MARINO, DO, MPH
ROBYN SOCKOLOW, MD

Gastroesophageal reflux is a common problem that occurs in the pediatric pop-

ulation. Gastroesophageal reflux refers to the retrograde passage of gastric con-
tents into the esophagus. Current thinking implicates transient lower esophageal
sphincter relaxations as a major cause for reflux. Infants generally present with
symptoms of regurgitation, whereas symptoms of esophagitis are more com-
mon in older children. When there are dangerous consequences secondary to
gastroesophageal reflux, it is termed gastroesophageal reflux disease (GERD).
GERD has been shown to manifest with respiratory symptoms and a pathologic
process. A variety of diagnostic procedures are available for the assessment of
GERD which include barium swallow, pH probe, scintigraphy, and endoscopy
with esophageal biopsy. Medical management of GERD primarily involves proki-
netic agents and acid suppression therapy. Surgical therapy, albeit less common,
now still has its role in the treatment of GERD.
(Key words: gastroesophageal reflux, gastroesophageal reflux disease, GERD)

G astroesophageal reflux is one of the

most prevalent gastrointestinal prob-
lems that occurs in children.1 The term
refers to the presence of gastric contents
proximal to the stomach.2 It is not
uncommon for many infants to have
recurrent problems of spitting up and
vomiting during the first year of life.2
This problem can range from the occa-
sional “burp and spit-up” to life-threat-
ening malnutrition from severe regurgi-
From the Department of Pediatrics,
Winthrop–University Hospital, Mineola, NY,
where Dr Sunku is chief resident in pediatrics; Dr
Marino is Director of General Pediatrics; and
Dr Sockolow is Chief of Pediatric Gastroen-
terology. Dr Marino is also a clinical professor of
pediatrics, State University of New York at Stony
Brook, and a clinical professor at New York
College of Osteopathic Medicine of New York
Institute of Technology, Old Westbury, NY.
Correspondence to Ronald V. Marino, DO,
MPH, Winthrop Pediatrics Associates, 222 Sta-
tion Plaza N, Suite 611, Mineola, NY 11501-
3957.
E-mail: rmarino@winthrop.org
tation with failure to thrive. When dan-
gerous consequences exist secondary to
the gastroesophageal reflux, it is termed
gastroesophageal reflux disease (GERD).
It is important for the pediatrician to
make this distinction when evaluating a
child for possible intervention for GERD.
Gastroesophageal reflux is a physiologic
occurrence that takes place more often
during infancy and decreases with
advancing age. Evaluation of most of
these infants usually reveals no definable
anatomic, metabolic, infectious, or neu-
rologic cause of reflux.3
Physiology
GERD results from an increased fre-
quency or duration of reflux episodes,
from increased noxiousness of the reflux-
ate or from the refluxate reaching loca-
tions beyond the esophagus, such as the
airway, which can produce untoward
effects.1 The upper gastrointestinal (GI)
tract distal to the mid-esophagus is com-
posed of smooth muscle layers. It is the

Sunku et al • Pediatric gastroesophageal reflux JAOA • Vol 100 • No 12 • Supplement to December 2000 • S11
peristaltic wave of contraction using
these involuntary muscle layers which
propels ingested food forward through
the esophagus into the stomach.2 At the
distal end of the esophagus lies the ton-
ically contracted smooth muscle known
as the lower esophageal sphincter (LES).
This sphincter relaxes in accordance to
allow the bolus of food from the esoph-
agus to pass into the stomach. It is also
the main barrier to the retrograde move-
ment of gastric contents. It was previ-
ously thought that abnormalities in the
resting tone of the LES with persistent
LES hypotonia was responsible for gas-
troesophageal reflux during infancy. Cur-
rent theory supports the possibility that
the LES undergoes episodes of transient
relaxations out of coordination with the
normal esophageal peristaltic mecha-
nism. These transient LES relaxations
allow gastric contents to reflux into the
esophagus. This hypothesis is based on
current evidence showing this mecha-
nism to be the primary mode of reflux in
older children and adults with gastroe-
sophageal reflux.
Clinical presentation
Gastroesophageal reflux occurs to some
extent in all individuals throughout the
day. It is considered physiologic if the
person experiences no consequences of
this reflux. Complications usually do
not occur if the frequency and duration
of reflux are within the normal range.4
For example, infants with regurgitation
as the only manifestation of gastroe-
sophageal reflux are considered to have
physiologic reflux and are referred to as
“happy spitters.”2 Although many older
children and adults can report symp-
toms such as heartburn, infants often
present with different manifestations of
reflux. The majority of manifestations
of GERD in infants are supraesophageal,
with regurgitation being the most fre-
quently observed symptom of gastroe-
sophageal reflux in infants.5 Infantile
reflux becomes symptomatic during the
first few months of life, peaks by 4 to 5
months, and usually resolves by 12 to 24
months of age. More than 90% of
infants with reflux will stop vomiting
by 18 months of age.5 Because most of
S12 • JAOA • Vol 100 • No 12 • Supplement to December 2000
GASTROESOPHAGEAL REFLUX
 Gastrointestinal system

Emesis

Regurgitation

Failure to thrive

Belching

Choking

Gagging

Malnutrition

Rumination

Esophagitis

Chest pain

Irritability

Peptic stricture

Barrett’s esophagus

Excessive crying

Anemia

Bradycardia

Feeding refusal

Apparent life-threatening event

Dysphagia

Sandifer’s syndrome
(gastroesophageal reflux with tor-
ticollis)
Figure. Clinical presentations of gastroesophageal reflux.
these infants with symptoms of gastroe-
sophageal reflux are thriving and healthy,
they require little more than a careful
history and examination with appropri-
ate parental reassurance.
It is important to distinguish benign
gastroesophageal reflux from patholog-
ic GERD, which can manifest as mal-
nutrition, respiratory disorders, or
esophagitis and its complications. As
mentioned earlier, regurgitation is the
most common manifestation of infant
reflux. Although most often immediate-
ly postprandial, it can be delayed for up
to 2 hours after feedings. Important dif-
ferential diagnoses to be considered in
evaluating a child with regurgitation
include anatomic anomalies and milk
protein allergy.2 Weight loss is one of
 Respiratory system

Reactive airway disease

Apnea

Hiccups

Cough

Aspiration pneumonia

Bronchopulmonary dysplasia

Bronchitis

Stridor

Hoarseness

Subglottic stenosis

Laryngospasm

Sudden infant death syndrome
the most common findings associated
with regurgitant reflux. It may be sec-
ondary to both emesis with caloric loss
and anorexia (presumably due to
esophagitis).6 Crying and irritability
resulting from esophagitis may be the
nonverbal infant’s equivalent of the
adult’s complaints of heartburn and chest
pain. Also, behavior consisting of yawn-
ing, hiccups, arching, stretching, stridor,
and mouthing has also been shown to be
associated with onset of esophageal acid-
ification.3 Distinguishing these symp-
toms of gastroesophageal reflux from
infantile colic can be particularly chal-
lenging for the pediatrician. Inadequate
caloric intake may be secondary to
odynophagia, parental hesitancy to feed
the infant because of increased regurgi-
Sunku et al • Pediatric gastroesophageal reflux
tation, and increased losses secondary
to persistent emesis. It is important to
note that children with reflux-induced
failure to thrive first fall from the weight
curve and then may demonstrate a delay
in linear growth.8
Some important complications of
reflux and prolonged acid exposure are
strictures and Barrett’s esophagus. Bar-
rett’s esophagus is columnar metaplasia
of the distal esophagus. Because of the
limited chronicity of reflux in infants,
these presentations of prolonged acid
exposure are not as common in infants
but are nonetheless important to note.
Strictures can present with symptoms of
dysphagia in relation to ingestion of
solids and expulsion of undigested food.
The prevalence of Barrett’s esophagus
is rare in the pediatric population and is
often asymptomatic. The presence of
Barrett’s esophagus, however, increases
the risk of adenocarcinoma of the esoph-
agus later in life.9 Children with neuro-
logic impairments who are unable to
express symptoms such as heartburn are
at particular risk for long-term conse-
quences of GERD. Anemia and hypoal-
buminemia in this population should
alert the pediatrician to evaluating the
esophagus as a possible site of a patho-
logic process.
Association of gastroesophageal
reflux with respiratory symptoms
The cause-and-effect relationship
between respiratory symptoms and gas-
troesophageal reflux can often be quite
puzzling. Many reports have associated
reflux in children with upper and lower
respiratory tract disorders.3 Upper res-
piratory symptoms can result from aspi-
ration of esophageal contents into the
airway, causing edema and inflamma-
tion, which, in turn, can produce symp-
toms of stridor and laryngospasm. It is
also important to evaluate swallowing
function in some patients as aspiration of
oral contents may be the etiology of
pneumonia. A barium swallow under
fluoroscopy may show laryngeal pooling
of saliva as the source of upper respira-
tory tract irritation. Obstructive apnea
can result from laryngospasm; thus, it
is important that infants who present
Sunku et al • Pediatric gastroesophageal reflux
with symptoms such as an apparent life-
threatening event) be evaluated for reflux.
Lower respiratory tract symptoms such
as asthma, bronchitis, or pneumonia
have been frequently correlated with gas-
troesophageal reflux. These symptoms
are more common in older children and
may also result from similar mechanisms
of aspiration as mentioned earlier.
It has become clear that other mech-
anisms may also play an important role
in respiratory symptoms related to
reflux.7 It has been shown that instillation
of acid into the esophagus of asthmatic
patients increases airway resistance.4 This
reflex bronchospasm mediated via vagal
pathways has been shown to respond
to treatment of the reflux. Interestingly
enough, this relationship between respi-
ratory symptoms and reflux has more
than one facet. Many of the modes of
pharmacotherapy for a reactive airway,
including -adrenergic agonists and xan-
thines, can lower the LES tone, thereby
increasing the propensity for reflux. Also,
the increased abdominal pressure from
coughing and wheezing and the increased
negative intrathoracic pressure from hic-
cups and stridor can exacerbate reflux.8
Of further note, nocturnal symptoms,
including cough in an asthmatic patient,
are especially suggestive of underlying
reflux.
Diagnostic evaluation
Diagnostic evaluation begins with a
detailed history and physical examina-
tion. This approach is helpful in distin-
guishing nonreflux disorders from gas-
troesophageal reflux and in assessing
which patients can be managed simply
with conservative treatment.1 Each of
the diagnostic tests available can assess
reflux from different perspectives.3
Because numerous methods of evaluat-
ing reflux exist, some guidelines in test
selection may prove helpful. For patients
whose symptoms are suggestive of
esophagitis, esophagogastroduo-
denoscopy with an esophageal biopsy
would be a reasonable route. A pH
probe is useful in evaluating patients
with respiratory manifestations of reflux.
Barium fluoroscopy can be helpful in
suspected obstructive or anatomic
JAOA • Vol 100 • No 12 • Supplement to December 2000 • S13
anomalies. It also provides insight into
swallowing function. Endoscopy is ben-
eficial in assessing children to exclude
peptic ulcer disease and other causes of
gastritis/esophagitis such as Helicobacter
pylori infection.1
Barium swallow
Upper GI barium fluoroscopy is an
important diagnostic tool in evaluating a
child for reflux. Although not a sensi-
tive test in diagnosing GERD, it is useful
in eliminating other pathologic process-
es that can cause regurgitation in an
infant, including gastrointestinal obstruc-
tion, malrotation, intermittent volvulus,
and numerous other possible congeni-
tal causes for emesis. A contrast study of
the upper GI tract also can be useful in
ruling out the presence of a large hiatal
hernia. Barium esophagraphy has vari-
able sensitivity secondary to brief mon-
itoring time and poor specificity owing to
the presence of physiologic reflux in
healthy individuals.1 Also, a barium swal-
low is not helpful in terms of evaluating
gastric emptying.
Monitoring with pH probe
Esophageal pH monitoring has often
been called the “gold standard” for eval-
uating reflux. This test is helpful when
evaluating a child with nonregurgitant
reflux who presents with symptoms of
esophagitis. It can quantify the frequen-
cy and duration of reflux episodes.
Despite its utility in detecting reflux,
however, it is not helpful in determining
whether reflux is causing symptoms or
disease.7 Pediatric patients can tolerate
this test fairly well as it allows for the
ability to monitor a child in a nearly
physiologic setting with a normal dietary
intake for 24 hours. Although the pH
probe has the ability to detect acid reflux,
its sensitivity is greatly diminished in the
postprandial period, as ingested food or
formula buffers the gastric acidity. Even
though reflux of these contents may
occur, the buffering effect makes the pH
probe unable to detect it. To enhance
the sensitivity of this test, some have sug-
gested the use of apple juice (pH 3.5)
with some feedings during pH probe
monitoring.9 Finally, pH probe moni-
toring has also been used extensively to
evaluate response to therapy.
Scintigraphy
Scintigraphic evaluation for GERD uses
a gamma counter for continuous imag-
ing after a single technetium 99m radi-
olabeled meal.9 Also known as a “milk
scan,” this test has an advantage over
the pH probe of detecting reflux after a
physiologically neutral pH meal. The
rate of gastric emptying can also be eval-
uated by a milk scan, which can pro-
vide useful information for children with
diagnosed reflux and those undergoing
evaluation for fundoplication to deter-
mine whether they will need a proce-
dure to facilitate gastric emptying. The
gastroesophageal scintiscan can also
detect pulmonary aspiration of gastric
contents which may help to correlate
reflux with pulmonary symptomatology.
Disadvantages of this scan include its
insensitivity for late postprandial reflux,
the requirement for children to be immo-
bile for lengthy periods during the scan,
the brief period of evaluation, and inabil-
ity to rule out anatomic anomalies that
an upper gastrointestinal series can pro-
vide.
Endoscopy and esophageal biopsy
Endoscopy is useful in evaluating symp-
toms of esophagitis, including pain, dys-
phagia, vomiting, and hematemesis.1
Although these presentations are not as
common in infants, endoscopy and
esophageal biopsy can be valuable in
providing information on esophageal
histology. Strictures and Barrett’s esoph-
agus are being identified with greater
frequency. However, because of
increased use of endoscopy, it may be
difficult to accurately visualize the micro-
scopic changes of esophageal ulceration
or inflammation secondary to reflux of
gastric contents. Esophageal biopsy has
shown that basal cell hyperplasia of the
esophageal mucosa has been established
as the histologic criterion for reflux
esophagitis in older children and adults;
however, this finding is not always
apparent in the distal esophagus of
infants.3 The presence of intraepithelial
eosinophils has been found to have
S14 • JAOA • Vol 100 • No 12 • Supplement to December 2000
greater specificity in identifying reflux
esophagitis in infants. This should be
interpreted with caution because
eosinophilic esophagitis has also been
identified as its own entity apart from
reflux and associated with food aller-
gies in infants and children.9
Management
When considering management of reflux
in young children, it is important to take
into account that in contrast to older
children and adults, most infants with
symptomatic reflux will outgrow these
symptoms within a year.1 When begin-
ning therapy for gastroesophageal reflux,
one should always consider conserva-
tive therapy first, including lifestyle mod-
ifications. One can then proceed to phar-
macotherapy, including a prokinetic
agent and even acid-reducing therapy if
symptoms of esophagitis are present.
Finally, surgical management should be
reserved for patients with serious seque-
lae unresponsive to the previously men-
tioned modalities.
Lifestyle changes for infants begin
with postural manipulations to decrease
the incidence of reflux. Avoidance of
seated and supine positions, especially
postprandially, and encouragement of
prone positioning reduces the number
of reflux episodes5; however, placement
in the prone position has been associat-
ed with an increased incidence of sudden
infant death syndrome (SIDS). Most
SIDS that occur in the prone position
can be attributed to suffocation from
puffy bedding. Therefore, if this type of
bedding is eliminated and parents are
thoroughly educated regarding risks and
benefits, the prone position can be used.
The American Academy of Pediatrics
recommendation that most infants sleep
in a supine position exempts those with
GERD.10 Also in contradiction to pre-
vious recommendations, there has been
shown to be no additional benefits of
elevation of the head of the bed of
infants.
Dietary modifications for infants with
GERD include the thickening of milk
formula with rice cereal and decreasing
the volume at each feeding.10 This thick-
ened formula should result in increased
caloric content of feedings instead of the
usual 20 calories per ounce. This thera-
py has been shown to decrease the num-
ber and volume of emesis episodes.1 The
main side effects from these thickened
feedings include promoting constipation
and increasing the velocity of weight
gain. Small and frequent feedings are
also recommended in that they may
decrease gastric volumes and, therefore,
the quantity of reflux may decrease.
Clear liquids, such as water and juice,
should be eliminated from the diet.
Lifestyle modifications in older chil-
dren include changes in positioning and
dietary restrictions. Optimal positioning
includes maintaining an upright posi-
tion while awake and sleeping prone.
Elevating the head of the bed may pro-
vide benefit in this age group as opposed
to infants. Dietary measures include
avoidance of large meals, acidic foods
and beverages, and foods that lower LES
tone, including carbonated beverages,
coffee, and alcohol. Also, fasting sever-
al hours before bedtime might decrease
the number of reflux episodes. Chew-
ing gum is another product that should
be discouraged as aerophagia may be
increased with chewing. Weight reduc-
tion in obese individuals and avoidance
of tight clothing should also be encour-
aged. A final recommendation includes
avoiding exposure to tobacco smoke in
all ages of children.
Pharmacotherapy
Prokinetic pharmacotherapy has tradi-
tionally been the first choice of medica-
tion because these agents address the
most prominent clinical presentation,
regurgitation. Acid suppression is added
when esophagitis is clinically suspected or
demonstrated.9 Cisapride had been one
of the first choices for prokinetic agents
in managing reflux until its recent
removal from the market. Metoclo-
pramide hydrochloride has been found to
increase LES tone and gastric emptying
via dopaminergic effects.10 It has a rela-
tively narrow therapeutic window for
dosing. The most common side effects
are drowsiness and irritability. Although
extrapyramidal side effects with dyston-
ic reactions can occur, they are less com-
Sunku et al • Pediatric gastroesophageal reflux
mon in the pediatric population than in
adults. Bethanechol chloride, a mus-
carinic agonist, has been shown to
increase LES tone but is seldom used in
practice secondary to its relative ineffec-
tiveness in reducing reflux and its unde-
sirable side effects of cramping and diar-
rhea. Domperidone is similar in action to
metoclopramide, but recent studies3 have
found it to have only marginal benefits.
For patients in whom the diagnosis of
esophagitis is made, the addition of acid
suppression therapy can provide relief.
Histamine H2-blockers have been used
successfully in pediatric patients. Limit-
ed data, however, are available regarding
appropriate dosing in the pediatric age
group. It has been suggested that popu-
lar dosing regimens are probably sub-
therapeutic.10 Cimetidine and ranitidine
hydrochloride are the most widely used
of these agents. Proton pump inhibitors
provide much greater reduction in acid
secretion compared with histamine H2-
blockers and are often used in children
who require more complete acid sup-
pression, such as those with severe chron-
ic respiratory disease or neurologic
impairment.9 As with adults, the safety
of long-term therapy with omeprazole
is unknown at this time. Sucralfate has
also been shown to be a useful agent in
children with symptoms of primarily
esophagitis.
Surgical therapy
The Nissen fundoplication, which
involves a 360-degree wrap of the fundus
around the distal esophagus to increase
LES pressure, has been the most com-
mon procedure for GERD, with efficacy
rates ranging from 60% to greater than
90%.2 Sometimes a pyloroplasty is com-
bined with this procedure for patients
with delayed gastric emptying in addition
to GERD. The recent trend toward a
more conservative approach derives from
the fact that the developmental resolution
of GERD in infants usually occurs in
the second year of life. Failure of medi-
cal management is an accepted indication
for surgery and has been especially help-
ful in the case of children with neurologic
impairment, repaired esophageal atre-
sia, and chronic lung disease.11
Sunku et al • Pediatric gastroesophageal reflux
Comment
GERD is a well-recognized entity in
infants and children. It is important for
the physician to become skilled in dis-
tinguishing physiologic from pathologic
reflux. Many infants have regurgitation
as the primary presentation of reflux.
Although more common in older chil-
dren, symptoms of esophagitis should
not be ignored in infants. Also, one
should always consider reflux as a con-
tributory factor in a patient who has
chronic respiratory symptoms. The diag-
nosis of gastroesophageal reflux is ini-
tially based on clinical suspicion and can
be well supported by many tests that
may be indicated on the basis of the pri-
mary symptomatology. The pH probe is
probably the easiest to administer and
most widely used measure for docu-
menting reflux in young patients. The
management of gastroesophageal reflux
begins with first determining the need
for specific treatment based on age, nutri-
tional status, and response to previous
interventions. Most infants will outgrow
pathologic reflux within a year of diag-
nosis, and this likelihood should be taken
into serious consideration when con-
templating therapy, especially surgical
correction. Increased knowledge and
experience with prokinetic and acid-sup-
pressive agents hold the promise of great
benefit for our young patients.
JAOA • Vol 100 • No 12 • Supplement to December 2000 • S15
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