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Author: HarlandSWinter,MD

SectionEditor: BUKLi,MD
DeputyEditor: AlisonGHoppin,MD
ContributorDisclosures

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2016.|Thistopiclastupdated:Jul05,2016.
INTRODUCTIONGastroesophagealrefluxdisease(GERD)ispresentwhenpassageofgastriccontentsinto
theesophaguscausestroublesomesymptomsorcomplications[1].Therangeofsymptomsandcomplications
ofGERDinchildrenvarieswithage.
ThistopicreviewfocusesontheclinicalmanifestationsanddiagnosisofGERDinchildrenandadolescents.
Othertopicreviewsrelevanttogastroesophagealreflux(GER)andGERDinthepediatricagegroupare:
Managementofgastroesophagealrefluxdiseaseinchildrenandadolescents
Gastroesophagealrefluxininfants
Gastroesophagealrefluxinprematureinfants
Thesediscussionsaregenerallyconsistentwithanofficialconsensusstatementandsystematicreviewissued
bytheNorthAmericanSocietyofPediatricGastroenterology,HepatologyandNutrition(NASPGHAN)and
EuropeanSocietyofPediatricGastroenterology,HepatologyandNutrition(ESPGHAN)[1],andtheAmerican
AcademyofPediatrics(AAP)[2].ThefulltextoftheNASPGHANguidelinesisavailableatthesocietywebsite.
DEFINITIONS"Gastroesophagealreflux"(GER)referstotheretrogradepassageofgastriccontentsintothe
esophagus.Thisisanormalphysiologicprocessthatoccursinhealthyinfants,children,andadults.Most
episodesarebriefanddonotcausesymptoms,esophagealinjury,orothercomplications.Incontrast,
"gastroesophagealrefluxdisease"(GERD)ispresentwhentherefluxepisodesareassociatedwith
complicationsortroublesomesymptoms[1,2].
Theterm"regurgitate"describesrefluxtotheoropharynx,and"vomit"describesexpulsionoftherefluxateoutof
themouth,butnotnecessarilyrepetitivelyorwithforce.Thetermsareoftenusedinterchangeablyinclinical
practice.Inthisreview,wewillusetheterm"regurgitate"todescribeobviousGERintothemouth,whetheror
nottherefluxateisexpelledfromthemouth.RecurrentregurgitationandvomitingareoftencausedbyGER,but
occasionallyarecausedbymoreseriousproblems,includingunderlyinganatomic,metabolic,orneurologic
abnormalities,whichshouldbeconsideredwhenindicatedbythepatient'sclinicalpresentation.(See'Recurrent
vomitingorregurgitation'below.)
Theterm"rumination"describesaseparatephenomenoninwhichfoodisvoluntarilyregurgitatedintothe
mouth,masticated,thenreswallowed.ThisdisordershouldbeconsideredasapossiblecauseofGER,butit
hasabehavioraletiologyandtreatment.(See'Recurrentvomitingorregurgitation'belowand"Approachtothe
infantorchildwithnauseaandvomiting",sectionon'Ruminationsyndrome'.)
EPIDEMIOLOGYFewlargepopulationbasedstudieshavedescribedtheepidemiologyofgastroesophageal
refluxdisease(GERD)inchildren.MoststudiesfocusontheprevalenceofGERDinspecificgroups.
ComparisonamongstudiesisalsolimitedbytheuseofdifferentdefinitionsofGERDandthevariableextentto
whichotherpossiblecausesofsymptomsthatwereattributedtoGERDwereinvestigated.

PrevalenceAccordingtoalargecommunitybasedstudyofchildrenintheUnitedStates,theprevalenceof
varioussymptomssuggestiveofgastroesophagealreflux(GER)was1.8to8.2percent[3].Amongadolescents,
3to5percentcomplainedofheartburnorepigastricpain,and1to2percentusedantacidsoracidsuppressing
medication.TheprevalenceofGERDinadultsinthewesternworldisapproximately10to20percent[4].
Contrarytopreviouslyheldbeliefs,GERDdoesnotappeartobelimitedtowesterncountries.Theprevalenceof
GERDinchildrenappearstoberisingworldwide,althoughitisunclearwhethertherisereflectsincreasingcase
identification,orincreasesinobesityorotherconditionsthatpromoteGERD[5].
HigherratesofGERDareseenamongchildrenwithdevelopmentalandneuromusculardisorderssuchas
cerebralpalsyandmusculardystrophy.ChildrenwithDownsyndromearealsoatincreasedriskforGERDand
otheresophagealmotorabnormalitiesforreasonsthatarepoorlyunderstood[6,7].Thesegroupsofchildren
alsoappeartobeatincreasedriskfordevelopingrespiratorycomplicationsrelatedtoGERDandrepresenta
significantproportionofchildrenreferredforantirefluxsurgery.ComplicationsofGERD,includingBarrett
esophagusandesophagealadenocarcinoma,aremorecommoninindividualswhohadrepairofesophageal
atresiaintheperinatalperiodascomparedwithindividualswithoutthiscongenitaldefect[8,9].GERDalso
appearstoberelativelycommoninchildrenwithobesityorcysticfibrosis[1].(See"Cysticfibrosis:Overviewof
gastrointestinaldisease".)
NaturalhistoryRegurgitationininfantsiscommonandtypicallydecreasesorresolvesduringthefirstyear
oflife(see"Gastroesophagealrefluxininfants").Althoughtheproblemusuallyresolvesbytheendofinfancy,
thereisaweakassociationwithGERDlaterinlife.Asanexample,frequentregurgitationduringinfancyora
historyofGERDinthemother(butnotthefather)predictstheriskofrefluxrelatedsymptomsduringchildhood.
Thiswasdemonstratedinaprospectivecohortstudyinwhichchildrenwhohadmorethan90daysoffrequent
regurgitationduringthefirsttwoyearsoflifeweremorelikelytohaveheartburnaroundnineyearsofage[10].
SymptomsofGERDduringchildhoodaremoderatelylikelytopersistintoadolescenceandadulthood
("tracking").Inasurveyof207patientswhowerediagnosedwithGERDthroughanendoscopicexamination
showingesophagitisinchildhood(meanagefiveyears),aboutonethirdhadsymptomsofsignificantGERD
duringearlyadulthood(approximately15yearslater)[11].Atleast9(upto23)percenthadweeklysymptomsof
GER.Amongthoserespondingtothesurvey,30percentwerecurrentlytakingacidsuppressingmedications,
and24percenthadundergonefundoplication.Otherstudieshaveshownsimilarresults,butthelackof
prospectivetrialslimitsthereliabilityoftheseobservations[12].
SeveralquestionsrelatedtotheepidemiologyandnaturalhistoryofGERDinchildrenremainunanswered.We
haveonlyapartialunderstandingoftherelationshipbetweenGERandrespiratorydiseases,includingasthma,
chroniccough,andrecurrentpneumonia.Inaddition,therelationshipbetweenchildhoodGERDandGERD
relatedcomplicationsinadulthoodisunclear.Finally,thehealthcareburdenrelatedtothediagnosisand
treatmentofchildhoodGERDandtheimpactofGERDonqualityoflifeforchildrenandtheirfamilieshavenot
beenfullyexamined.
CLINICALMANIFESTATIONSThemostcommonsymptomsofgastroesophagealreflux(GER)and
gastroesophagealrefluxdisease(GERD)varyaccordingtoage,althoughoverlapmayexist.
InfantsGERiscommonininfantsandusuallyisnotpathological.Regurgitationispresentin50to70
percentofallinfants,peaksatagefourtosixmonths,andtypicallyresolvesbyoneyear.Asmallminorityof
infantswithGERdevelopothersymptomssuggestiveofGERD,includingirritability,feedingrefusal,
hematemesis,anemia,respiratorysymptoms,andfailuretothrive.Theclinicalmanifestationsand
managementofGERinthisagegroupisdiscussedseparately.(See"Gastroesophagealrefluxininfants".)
PreschoolPreschoolagechildrenwithGERDmaypresentwithintermittentregurgitation.Lesscommonly,
theymayhaverespiratorycomplicationsincludingpersistentwheezing.Decreasedfoodintake,poorweight

gain,orfoodaversionwithoutanyothercomplaintsmaybeasymptominyoungchildren.Allofthese
symptomsarenonspecificandinsufficienttomakeadefinitivediagnosisofGERD.Amorespecific
symptomofGERDisSandifersyndrome,anunusualposturingconsistingofarchingoftheback,torsionof
theneck,andliftingupofthechin[1].Sandifersyndromeisfoundintypicallydevelopingpreschoolaged
children,aswellasthosewhoaredevelopmentallydelayed,asintheoriginaldescriptions.(See"Acquired
torticollisinchildren",sectionon'Sandifersyndrome'.)
SchoolagedchildrenandadolescentsThepatternofsymptomsandcomplicationsofGERDinolder
childrenandadolescentsresemblesthatseeninadults.Thecardinalsymptomsarechronicheartburn
and/orregurgitation[13].ComplicationsofGERD,includingesophagitis,strictures,Barrettesophagus,and
hoarsenessduetorefluxinducedlaryngitis,alsomaybeseen.Olderchildrenmaycomplainofnausea,
dysphagia(difficultyswallowing)and/orepigastricpain,butmanypreadolescentswillnotlocalizepainand
reportdiffuseabdominaldiscomfort.(See"Barrett'sesophagus:Epidemiology,clinicalmanifestations,and
diagnosis"and"Approachtochroniccoughinchildren".)
GERDrelatedchestpainisnotwelldescribedbyyoungchildren.Youngornonverbalchildrenmaybeobserved
poundingtheirchest.GERDiscommoninchildrenwithautism,andmaybemanifestedonlybyunexplainedor
selfinjuriousbehaviors.Inolderchildren,chestpaintypicallyisdescribedassqueezingorburning,located
substernallysometimesradiatingtotheback,lastingfromminutestohours,andresolvingeitherspontaneously
orwithantacids.Itusuallyoccursaftermeals,awakenspatientsfromsleep,andmaybeexacerbatedby
emotionalstress.

ExtraesophagealdisordersthatareassociatedwithGERDalsomaybeseeninolderchildrenandadolescents.
Inalargecasecontrolstudyofchildrenwithoutneurologicdefects,GERDwasanindependentriskfactorfor
developingsinusitis(adjustedoddsratio[OR]2.3),laryngitis(OR2.6),asthma(OR1.9),pneumonia(OR2.3),
andbronchiectasis(OR2.3)(see'Asthma'belowand'Recurrentpneumonia'below)[14].GERisalso
hypothesizedtocontributetootitismediawitheffusion,butcausalityhasnotbeenproven.(See"Otitismedia
witheffusion(serousotitismedia)inchildren:Clinicalfeaturesanddiagnosis",sectionon'Pathogenesis'.)
AVAILABLEDIAGNOSTICTECHNIQUESThefollowingsectionssummarizecharacteristicsoftheteststhat
areusedtoevaluateindividualswithsymptomsofgastroesophagealreflux(GER)orgastroesophagealreflux
disease(GERD).Theclinicalapproachtoselectingamongthesetestsdependsonthepatient'spresenting
characteristics.(See'Suggestedapproachforcommonclinicalscenarios'below.)
EmpirictreatmentAnempirictrialofacidsuppressionisoftenusedasadiagnostictest,andissuggested
forolderchildrenandadolescentswithuncomplicatedheartburn[1].Thetrialtypicallyconsistsofatwotofour
weekcourseofacidsuppressingmedication(eg,aprotonpumpinhibitor[PPI]).AnempirictrialofaPPImay
notbeavaluablediagnostictestininfantsandyoungchildren,inwhomsymptomsofGERDarelessspecific
however,responseafteratwoweektrialofaPPIhasbeenusedasinclusioncriteriaforclinicaltrialsininfants
withGER[15].Studiesinadultssuggestthatempirictreatmentisacosteffectiveapproachinselectedpatients,
althoughtheapplicabilityoftheseresultstochildrenisuncertain[16].(See'Heartburn'belowand"Medical
managementofgastroesophagealrefluxdiseaseinadults".)
BariumcontrastradiographyBariumstudiesoftheesophagusareneithersensitivenorspecificforthe
diagnosisofGERD.WhencomparedwithesophagealpHstudies,bariumstudiesoftheesophagushavea
sensitivityrangingfrom31to86percent,specificityof21to83percent,andpositivepredictivevalueof80to82
percent[1722].
AlthoughradiologicevaluationisnotusefultoconfirmorexcludeGERD[1,2,23],imagingisusefulinayoung
infantwithintractablereflux,toidentifycongenitalabnormalitiessuchasanantralweb,annularpancreas,or
malrotation[24].Imagingmayalsobeusefulintheevaluationofselectedpatientswithatypicalpresenting

features,suchasdysphagiaorodynophagia,inwhomitmayidentifyhiatalhernia,achalasia,orstrictures
associatedwithacidoreosinophilicesophagitis.(See'Dysphagiaorodynophagia'below.)
EndoscopyandhistologyEndoscopicevaluationoftheuppergastrointestinaltractisindicatedforselected
patientsinwhomesophagitisorgastritisissuspected.Theseincludechildrenoradolescentswithheartburn,
hematemesis,orepigastricabdominalpainthatfailstorespondtoorrelapsesquicklyafterempirictreatment
[1,23].Inaddition,endoscopymaybevaluableintheevaluationofpatientswithrecurrentregurgitation,
dysphagia,odynophagia,orahistoryoffoodimpaction,orinchildrenwithfrequentGERthatpersistedfrom
infancyuntilaftertwoyearsofage.
Atendoscopy,theexaminerinspectsthevisualappearanceoftheesophagealmucosaandanatomy,andtakes
aseriesofbiopsiesforhistologicexamination.Thefindingshelptodeterminethepresenceandseverityof
esophagitisandcomplications,suchasstricturesorBarrettesophagus,andtoexcludeotherdisorderssuchas
eosinophilic,peptic,orinfectiousesophagitis.Thediagnosticyieldofendoscopyinchildrenwithsymptoms
suggestingGERDisnotwellestablished.InonelargeseriesofchildrenundergoingendoscopyduetoGERD
symptoms,35percentwerefoundtohaveerosiveesophagitis[25].Inanotherlargeseriesofchildren
undergoingendoscopyforGER,only13percenthadhistologicevidenceofesophagitis,whereasmorethan50
percentofthoseundergoingendoscopyfordysphagiahadgrossandhistologicabnormalities[26].
Endoscopycanbeperformedsafelyininfants,toddlers,andolderchildren.Procedurerelatedcomplicationsof
diagnosticendoscopyandbiopsyarerare[27].Complicationsrequiringmedicalattention,includingunderor
oversedation,occurinabout5percentofcases[28,29].Themostcommoncomplicationistransientsorethroat
orhoarseness,whichoccursinabout35percentofpatients[29].
Theendoscopyshouldincludebiopsiesoftheesophagealmucosatoevaluateforesophagitis,evenifthe
esophagusappearsnormalonvisualinspection[1,2,30].HistologicabnormalitiesconsistentwithGERDinclude
increasednumbersofintraepithelialeosinophils,thickeningofthebasalcelllayer,andelongationofthe
epithelialpapillae[15,31,32].Inyoungchildrenwithesophagitis,thefindingsofbasalzonehyperplasiaare
uncommon,andotherhistologicfeatures,suchasthepresenceofneutrophilsandeosinophils,anddilated
vascularchannelsinpapillaeofthelaminapropriaaremoretypicallyseen[15].Patientswithrefluxassociated
esophagitisshouldbetreatedwithacidsuppression,asdiscussedinaseparatetopicreview.(See
"Managementofgastroesophagealrefluxdiseaseinchildrenandadolescents",sectionon'Esophagitis'.)
ThehistologicfeaturesdescribedaboveareonlymoderatelyspecificforGERD.Inpatientswithmarkedly
increasednumbersofeosinophilsinesophagealbiopsies,thepossibilityofeosinophilicesophagitis(EoE)
shouldbeconsidered.EoEisachronicimmunemediateddisordercharacterizedbymarkedlyincreased
intraepithelialeosinophilsingreaternumbersthannotedinGERD.SymptomsofEoEandthenumberof
intraepithelialeosinophilsmaynotrespondtoacidsuppression.EoEisincreasinglyrecognizedinchildrenand
adults,andthesymptomsandhistologicalfindingsoverlapwiththoseofGERD,suchthatinsomecasesitcan
bedifficultclearlydistinguishbetweenthedisorders[33,34].Thenumberanddistributionofeosinophilscanhelp
distinguishGERDfromEoE.InchildrenwithGERD,theeosinophilicinflammationtendstobemild(<15
eosinophilsperhighpowerfield)andlimitedtothedistalesophagus,whereasinchildrenwithEoEthe
inflammationtendstobesevere(>15eosinophilsperhighpowerfield)andlocatedinthemidorproximal
esophagus.Inaddition,manypatientswithEoEhaveahistoryofatopyorperipheraleosinophilia,andaremore
likelytofailtorespondtoantirefluxtreatment.Diagnosticandtreatmentapproachestopatientswithsuspected
EoEarediscussedinaseparatetopicreview.(See"Clinicalmanifestationsanddiagnosisofeosinophilic
esophagitis".)
EsophagealpHmonitoringorimpedancemonitoringEsophagealpHmonitoringpermitsthe
assessmentofthefrequencyanddurationofesophagealacidexposureanditsrelationshiptosymptoms.
However,theresultsmaynotcorrelateconsistentlywithsymptomseverity,althoughthereisacorrelationwith

thepresenceofesophagitisonendoscopy[1,32,35].Therefore,pHmonitoringcanraiseorlowersuspicionof
GERD,butisnotadefinitivediagnostictest,andisnotusefulinmanyclinicalsituations,especiallyininfants.
Toperformthetest,amicroelectrodeattachedtoasmallcatheterispassedthroughthenoseandpositionedin
thedistalesophagus.Thepositioncanbeverifiedradiologically.Inspecialsituations,multiplesensorscanbe
usedtodetermineifacidrefluxextendsintotheproximalesophagus.Therearealsodevicesthatcliptothe
esophagealmucosaandremaininplacefor24hours,toallowrecordingofintraesophagealpHwithoutthe
transnasalcatheter.Thistechnologycanbeusedforolderchildrenandisparticularlybeneficialforchildrenwith
autisminwhomtransnasalpHmonitoringisoftendifficulttoperform.
The"refluxindex"isdefinedasthepercentageoftotaltimethattheesophagealpHislessthan4thisprovides
anestimateofthecumulativeesophagealacidexposure,whichisconsideredtobethemostvalidmeasureof
reflux.However,thereisonlyaweakcorrelationbetweentherefluxindexandclinicalsymptoms,presenceof
esophagealdisease,orresponsetotherapy,andresultsofesophagealpHmonitoringshouldbeinterpretedin
thecontextofotherclinicalinformation.Therefluxindexusuallyisinterpretedasfollows[1]:
InfantsRefluxindexabove7percentisconsideredabnormal,andbetween3and7percentis
indeterminate.
OlderchildrenandadultsUpperlimitofnormalfortherefluxindexbetween4and7percent.
Multichannelintraluminalimpedancemonitoring(MII)isanewertechniquethatpermitsmeasurementofall
refluxepisodes,includingthosethatareacidic,weaklyacidicandalkaline.MIIisnowavailableatmanycenters,
andusuallyisusedincombinationwithpHmonitoringsothatepisodesofacidrefluxmaybedistinguishedfrom
nonacidreflux.Inatrialcomparingthetwotechniques,combinedMIIpHmonitoringdetectedrefluxeventsthat
causedsymptomstwiceasoftenaspHmonitoringalone[36].AlthoughpediatricstandardsforMIIhavenot
beenestablished,thetechniquecanbehelpfultodeterminewhetherthereisacorrelationbetweenreflux
episodesandcertainsymptoms.MIIisdiscussedinaseparatetopicreview.(See"Esophagealmultichannel
intraluminalimpedancetesting".)
UsesEsophagealpHmonitoringorMIIcanbeusefulinthefollowingclinicalsituations[1,23,37]:
AtypicalsymptomsofrefluxInpatientswiththefollowingsymptoms,esophagealpHorMII/pHmonitoring
issometimesusefultodeterminewhetherthereisatemporalcorrelationbetweensymptomsandepisodes
ofreflux.
LaryngealsymptomsNocturnalstridororcoughraisethepossibilityofanassociationwithGERD.A
dualchannelesophagealpHmonitor,withelectrodesinbothdistalandproximalesophagus,is
particularlyvaluableforevaluatingpatientswiththesesymptoms.However,noconsensusexistsonthe
pHcriteriathatshouldbeusedfordefiningpathologicrefluxinthissetting[38,39].
AtypicalasthmaWheezingthatispositional(eg,recumbent)innature,orasthmathatissevere,non
seasonal,andrefractorytostandardtreatment,raisethepossibilityofanassociationwithGERD.In
patientswithsuchsymptoms,esophagealpHorMII/pHmonitoringcanassesswhetherthereisa
temporalcorrelationbetweensymptomsandGER[40].However,empirictrialsofacidsuppression
alsomaybeusedinthissituation.(See'Asthma'below.)
RecurrentpneumoniaInpatientswithrecurrentpneumonia,itisdifficulttoestablishwhether
esophagealrefluxcontributestotheproblem.Althoughpatientswithaspirationtendtorefluxmore
frequentlyintotheproximalesophagusascomparedwithhealthypatients,esophagealpHmonitoring
haslowsensitivityandspecificityindetectingwhetheraspirationpneumoniaisrelatedtorefluxinthe
individualpatient[37].Nonetheless,esophagealpHorMII/pHmonitoringmayhelpestablishthe

diagnosisinselectedpatientswithsuspectedaspiration,whencombinedwithotherinvestigations,
includingvideofluoroscopicswallowingevaluation,bronchoscopy,and/orendoscopy.(See'Recurrent
pneumonia'below.)
NonverbalchildrenwithsuspectedGERDInnonverbalchildren(eg,thosewithautism),behavioral
changesorselfinjuriousbehaviormaybetheonlysymptomsofGERD.Inthiscase,anempirictrialof
acidsuppressingmedicationor,insomepatients,esophagealpHorMII/pHmonitoring,canbeusedto
assesswhetherthereisatemporalcorrelationbetweenrefluxeventsandthebehavioralsymptoms.
Upperendoscopymayalsobebeneficialindiagnosingesophagitis.
DistinguishingbetweenGERDandEoEBothEoEandGERDareassociatedwithincreasedeosinophils
intheesophagus,andinsomechildrendistinguishingbetweenthedisordersmaybedifficult.Inthis
situation,atrialofsustainedacidsuppressionisperformedtoexcludeGERDasacauseoftheesophageal
eosinophilia.Tocompoundtheproblemofdistinguishingthetwoconditions,thereisanentityknownas
PPIresponsiveEoE,whichmayormaynotbedistinctfromEoE.Alternatively(orinaddition),
documentationofanormalesophagealpHorMII/pHmonitoringhelpstosupportadiagnosisofEoE.(See
"Clinicalmanifestationsanddiagnosisofeosinophilicesophagitis".)
GastroesophagealrefluxsymptomsnotresponsivetomedicalorsurgicaltherapyEsophagealpHstudies
candeterminetheadequacyofacidsuppressioninchildrenwhoremainsymptomaticdespitebeingtreated
withaPPI,oraftersurgicaltreatmentforGERD.IfthepHstudyshowsadequateacidsuppression,
alternativeexplanationsforthesymptomsshouldbesought(eg,EoEoralkalinereflux).Ifuncontrolledacid
refluxisdocumented,acidsuppressivetreatmentshouldbeoptimized.(See"Managementof
gastroesophagealrefluxdiseaseinchildrenandadolescents",sectionon'Pharmacotherapy'.)
InfantswithapneaIfinfantshaverepeatedepisodesofapnea,esophagealpHorMII/pHmonitoringmay
beusefultodetermineifthesearetriggeredbyGERD.However,theassociationcanbemadeonlyif
positiveeventsareidentifiedsimultaneouslybypolysomnographyoroxycardiorespirography.Thesetests
arenotusefulfortheroutineevaluationofinfantswhohaveexperiencedanapparentlifethreateningevent
(ALTE),exceptinselectedpatientswithrecurrentALTE.(See"Gastroesophagealrefluxininfants"and
"Acuteeventsininfancyincludingbriefresolvedunexplainedevent(BRUE)",sectionon'Gastroesophageal
refluxorswallowingdysfunction'.)
LimitationsEsophagealpHorMII/pHmonitoringdoesnotdetectanatomicalabnormalitiesor
esophagitis.Thus,itisnotgenerallyusefulinthefollowingclinicalsituations[13,37]:
EvaluationofpatientspresentingwithtypicalsymptomsofGER,heartburn,orepigastricpainEmpiric
trialsofacidsuppressionandendoscopywillprovidemoredefinitiveinformationabouttheclinicaldiagnosis
andseverityforthesepatients.(See'Heartburn'below.)
PatientswithesophagitisdiagnosedbyendoscopyAbnormalrefluxindexcorrelatesstronglywiththe
presenceofesophagitisonendoscopy(approximately95percentofchildrenwithesophagitiswillhavean
abnormalrefluxindex)[32,35],butdoesnotcontributetothediagnosisoftheesophagitis.Therefore,
esophagealpHorMII/pHmonitoringisnotahelpfulinvestigationinpatientswithestablishedesophagitis,
excepttoinvestigatereasonsforinadequateresponsetotherapy.
PatientsinwhomalkalinerefluxissuspectedInsomepatients,alkaline(ratherthanacid)refluxis
suspectedduetopyloricinsufficiencyorotherabnormalities.Inthiscase,standardesophagealpH
monitoringisnothelpful,butMII(orcombinedMIIandpHmonitoring)maybebeneficialindetectingneutral
andalkalinereflux.(See"Esophagealmultichannelintraluminalimpedancetesting".)

InfantswithfrequentregurgitationIninfants,esophagealpHorMII/pHmonitoringisgenerallynotuseful
todistinguishbetweeninfantswithuncomplicatedrefluxandthosewithesophagitisorotherpathological
manifestationsofGERD.InfantswithfailuretothriveorothersymptomssuggestingpathologicalGERD
requireevaluation,butesophagealpHorMII/pHmonitoringisrarelyhelpfulinestablishingthediagnosis
[1,37].However,inselectedinfantswithdiscreteepisodesofirritabilityorothersymptomsthoughttobe
relatedtoGER,thesetestsmaybeusedtoestablishwhetherthereisatemporalrelationshipbetween
occultrefluxepisodesandtheirspecificsymptoms.(See"Gastroesophagealrefluxininfants".)
BronchoalveolarlavageBronchoscopywithbronchoalveolarlavageisoccasionallyusedtoassessfor
evidenceofrecurrentsmallvolumeaspiration.Ifaspiratescontainahighpercentageoflipidladen
macrophages,aspirationisthoughttobemorelikely.However,thistechniquehaslowsensitivityandspecificity.
Evenwithcarefulmeasurementprotocols,thereisconsiderableoverlapinfindingsbetweenpatientswith
aspirationandnormalcontrols,sothetechniqueisnotgenerallyuseful[1,41].(See"Aspirationdueto
swallowingdysfunctionininfantsandchildren",sectionon'Potentialbiomarkersofaspiration'.)
NuclearscintigraphyTestsemployingnuclearscintigraphyaredesignedtodetectaspirationand/or
delayedgastricemptying.However,duetolowsensitivityandspecificitytheyhavealimitedroleinthediagnosis
andmanagementofGERDinchildren.Smallamountsoftechnetium99mareeithermixedwithmilkandgiven
tothepatienttodrink(gastroesophagealscintigraphy,alsoknownasa"milkscan")ordirectlyinstilledintothe
mouth(salivagram).Gammacameraimagesofthechestaretakenatintervalstodetectthedistributionofthe
isotopeinthestomach,esophagus,andlungs.(See"Aspirationduetoswallowingdysfunctionininfantsand
children",sectionon'Gastroesophagealscintigraphyandsalivagram'.)
Gastrointestinalscintigraphy(milkscan)candetectaspirationofrefluxedmaterialintothelungs,unlike
esophagealpHmonitoringorMII.However,itssensitivityandspecificityarepoorwhencomparedwithother
clinicalorradiographicmeasuresofaspiration.Asaresult,thistesthasalimitedroleinthediagnosisand
managementofGERDinchildren[1,2].Thesametechniquecanbeusedtodetectabnormalitiesingastric
emptying,whichmaybevaluablewhengastroparesisissuspectedasacauseofthereflux,orwhensurgical
interventionforGERDiscontemplated.(See"Approachtotheinfantorchildwithnauseaandvomiting",section
on'Gastroparesis'and"Gastroparesis:Etiology,clinicalmanifestations,anddiagnosis",sectionon'Scintigraphic
gastricemptying'.)
Inselectedpatientswhoexperiencerecurrentaspiration,asalivagrammaybehelpfulindeterminingwhether
theaspirationiscausedbyswallowingproblems(antegradeaspiration)asopposedtoGERD(retrograde
aspiration)[42].However,salivagramsappeartohavelowspecificityduetofrequentfalsepositiveresults,
especiallyininfantsandyoungchildren,andmustbecorrelatedwithclinicalevidenceforaspiration.(See
"Aspirationduetoswallowingdysfunctionininfantsandchildren",sectionon'Gastroesophagealscintigraphy
andsalivagram'.)
EsophagealmanometryEsophagealmanometryisofminimaluseinthediagnosisoftypicalGERD[1].Its
mainpurposeistodiagnoseaprimarymotordisordersuchasachalasiainpatientswithsuggestivefindingson
bariumcontrastradiography.Inaddition,someprovidersuseesophagealmanometrytoevaluateperistaltic
functionbeforeantirefluxsurgery.Ifsignificantesophagealdysmotilityisdetected,antirefluxsurgeryshouldbe
approachedwithcaution,becauseitmightexacerbatedifficultieswithswallowingfoodand/orsaliva.(See
"Surgicalmanagementofgastroesophagealrefluxinadults".)
DIAGNOSTICAPPROACH
HistoryThedifferentialdiagnosisofgastroesophagealrefluxdisease(GERD)inchildrenisbroad,
particularlywhentheprincipalcomplaintisregurgitation,vomiting,orabdominalpain(table1).Thediagnostic
possibilitiescanbenarrowedbasedupontheageofthechildandthepatternofsymptoms,usingathorough

medicalhistory(table2)(see"Approachtotheinfantorchildwithnauseaandvomiting").Thehistoryshould
includethefollowingelements:
Presenceofheartburnorabdominalpain,regurgitationorvomiting,waterbrash,andwhetherthereis
associatednausea
Onsetofsymptomsandrelationtomeals
Dysphagia(difficultyswallowing)orodynophagia(painwhileswallowing)
Underlyingdisordersincludingneurologicdysfunctionorcongenitalanomalies
Asthma,pneumonia,orchroniccough
Medicationhistory
Inadditiontotheabove,thehistoryshouldseekinformationaboutoccultorrecognizedconstipation.Thisis
becausefunctionalconstipationisfrequentlyassociatedwithdyspepticsymptomsincludinggastroesophageal
reflux(GER),heartburn,andnausea[43,44].Inmanycases,theconstipationisunrecognizedandthedyspeptic
symptomsarethepresentingcomplaint[43].Thisprobablyoccursbecausetheconstipationdelaysgastric
emptyingviaanintraintestinalreflex,termedthe"cologastricbrake"[44].Arectalexaminationshouldbe
performedtodetermineiftherectalvaultispackedwithhardstool.Effectivetreatmentoftheunderlying
constipationmayrelievethedyspepticsymptomsandavoidinvasiveproceduresorlongtermpharmacotherapy
forpresumedGERD.(See"Constipationininfantsandchildren:Evaluation".)
SuggestedapproachforcommonclinicalscenariosThepreviousdiscussionunderscoresthevariable
presentationofGERDininfantsandchildrenandtheneedtomodifythediagnosticapproachbaseduponthe
patient'sage,typeofsymptoms,andtheirseverity.Thefollowingsectionswillprovidegeneralrecommendations
fordiagnosisininfantsandchildrenwithcommonlyseenclinicalpresentations.Theserecommendationsare
consistentwiththeguidelineissuedbytheNorthAmericanSocietyforPediatricGastroenterology,Hepatology,
andNutrition(NASPGHAN)[1].
RecurrentvomitingorregurgitationOtherwisehealthychildrenwithrecurrentvomitingorregurgitation
afterreachingtheageof18monthsusuallyrequireevaluation.Thedifferentialdiagnosisofregurgitationand
vomitingisbroad,anddependsontheagegroupandassociatedsymptoms(table1).Forotherwisehealthy
childrenandadolescentswithrecurrentregurgitationorvomitingandnoothersymptoms,athoroughhistory
andphysicalexaminationisoftensufficienttoexcludediagnosesotherthanGER.Foradolescents,theclinician
shouldspecificallyaskaboutcannabisuse.(See"Cannabisuseanddisorder:Epidemiology,comorbidity,health
consequences,andmedicolegalstatus",sectionon'Hyperemesissyndrome'.)
WarningsignsthatsuggestadiagnosisotherthanGERDincludefever,weightlossorfalteringgrowth,
abdominaltendernessordistension,biliousvomiting,markedhematemesis,hepatosplenomegaly,headacheor
newneurologicsymptoms,orothersystemicsymptoms.Patientswithanyofthesefeatureswarrantadditional
stepsintheevaluation.(See"Approachtotheinfantorchildwithnauseaandvomiting".)
ThedifferentialdiagnosisofGERDincludesseveraldisordersthatshouldbeexploredbythehistory:
GastroparesisGastroparesisistheconditionofimpairedgastricemptying.Thismaycausepostprandial
vomiting,whichusuallyoccursseveralhoursaftereating.Viralinducedgastroparesismaybeginacutely
afteranepisodeofgastroenteritisandpersistforseveralweeksormonthsthereafter,andoccasionallyas
longas18months.(See"Approachtotheinfantorchildwithnauseaandvomiting",sectionon
'Gastroparesis'.)

RuminationorpsychogenicvomitingRuminationsyndromeisapsychogenicdisorderinwhichthe
individualvoluntarilyregurgitatesandreswallowsfood,apparentlyasaselfcomfortingorhabitual
measure.Therepeatedepisodesusuallyoccurimmediatelyafterameal.Ruminationismorecommon
amongindividualswithdevelopmentaldisabilitiesbutalsooccursamongtypicallydevelopingchildren,
adolescents,andadults.Thedisordermaybeinitiallytriggeredbyanepisodeofgastroenteritis,GERD,or
bybodyweightconcerns,asaformofbulimia[45].DistinguishingruminationfromGERDmaybedifficult,
andrequiresahighindexofsuspicion.(See"Approachtotheinfantorchildwithnauseaandvomiting",
sectionon'Ruminationsyndrome'and"Approachtotheinfantorchildwithnauseaandvomiting",section
on'Bulimiaorpsychogenicvomiting'and"Eatingdisorders:Overviewofepidemiology,clinicalfeatures,and
diagnosis".)
PregnancyForpostmenarchalgirlswithvomiting,theclinicianshouldexplorethepossibilityofpregnancy,
withtestingifindicated.
Additionalevaluationisappropriateifthehistorydoesnotsuggesttheabovedisorders,andiftheGER
symptomsarefrequent,cyclicalorpersistent,andcausedistress.Inthiscase,theevaluationusuallyshould
includeanuppergastrointestinalseriestolookforanatomicabnormalities.Anupperendoscopywithbiopsy
maybehelpfulindeterminingifthechildhasesophagitis(eitherpepticoreosinophilicesophagitis).Inolder
childrenoradolescentswithheartburnorothersymptomssuggestiveofGERD,atwotofourweektrialofacid
suppressionmaybeusedasadiagnostictestforpepticdiseaseasanalternativetoendoscopy[1].
HeartburnChildrenoradolescentswithheartburncanbetreatedempiricallywithlifestylechangesandan
empirictrialofacidsuppressingmedication(eg,PPI)fortwotofourweeks.Aclearandcompleteresponseto
acidsuppressionsupportsthediagnosisofGERD.Persistentorrecurrentsymptomsshouldpromptareferral
foranupperendoscopywithbiopsy,especiallyifanydysphagiaispresent.(See"Managementof
gastroesophagealrefluxdiseaseinchildrenandadolescents",sectionon'Heartburn'.)
DysphagiaorodynophagiaPatientswithdysphagia(difficultyswallowing)orodynophagia(painwith
swallowing)usuallyshouldundergospecificevaluation.
Patientswithdysphagiatypicallycomplainofdifficultyinitiatingaswallow,orthesensationofsolidsorliquids
gettingstuckintheesophagus[13].Dysphagiaforsolidsismostcommonlycausedbyesophagealinflammation
relatedtoGERD,eosinophilicesophagitis,oresophagealstricture[46].Thesepatientsshouldbeevaluatedby
upperendoscopywithbiopsies,toexaminetheesophagealmucosa.Dysphagiaforliquidsaswellassolids
raisesthepossibilityofamotilitydisordersuchasachalasia.Thefirststepintheevaluationforachalasiaisa
radiographofthechest,lookingforalackofairinthestomachandanintraesophagealairfluidlevel.Abarium
esophagramisbeneficialtolookforesophagealdistensionandtheclassic'birdbeak'appearanceaswellasthe
possibilityofastricture.(See"Clinicalmanifestationsanddiagnosisofeosinophilicesophagitis"and"Achalasia:
Pathogenesis,clinicalmanifestations,anddiagnosis".)
Themostcommoncauseofodynophagia(painwithswallowing)inadolescentsispillesophagitis.Thisiscaused
bydirectmucosalinjurybycertaindrugsincludingtetracyclines(doxycyclineandminocycline)thatare
commonlyusedfortreatmentofacne,orbyantiinflammatoryagentsincludingaspirin.Pillesophagitisislikely
inpatientswhohavesuddenonsetofodynophagiaanytimeduringthecourseoftreatmentwithoneofthese
drugs,especiallyifthepillisswallowedwithlittleornoliquidand/ortakenjustbeforebedtime[1].Ifthe
symptomsaremild,thenitisreasonabletotreatthesepatientsempiricallywithsucralfateoraprotonpump
inhibitor(PPI)inadditiontostoppingtheoffendingmedication.Ifthesymptomsaresevereorprogressive,itis
importanttoperformanupperendoscopypriortoinitiatingtreatment,toexcludeinfectiouscausesof
esophagitisthatcauseodynophagia,includingcandida,cytomegalovirus,andherpes.(See"Medicationinduced
esophagitis".)

Uncommoncausesofdysphagiathatmaypresentinchildrenoradolescentsincludemotilitydisorders(eg,
myotonia)andsystemicsclerosis(scleroderma)(table3).(See"Overviewofdysphagiainadults",sectionon
'Differentialdiagnosisofesophagealdysphagia'.)
AsthmaGERmaybeatriggerforasthmainsomepatients.Abnormalreflux,asmeasuredbysymptoms
orbyesophagealpHmonitoring,occursin25to75percentofchildrenwithpersistentasthma,andthe
associationincreaseswithseverityofeithercondition,butwhetherthisassociationiscausalremainsunclear
[47,48].ManystudieshaveshownclinicalimprovementinasthmawhenpatientsaretreatedforGER[47,49].
However,predictingwhichpatientsarelikelytorespondtotreatmentremainsproblematic[1,50].
ForpatientswithasthmaandsymptomsthatstronglysuggestGERD(includingheartburninolderchildrenand
adolescents,orchronicregurgitationorvomitingininfantsandyoungerchildren),wesuggestathreemonthtrial
ofacidsuppression.(See"Managementofgastroesophagealrefluxdiseaseinchildrenandadolescents",
sectionon'AsthmawithGER'.)
GERmaytriggerasthmainsomepatientsevenintheabsenceofsymptomsofGERD.Therefore,manyexperts
recommendesophagealpHorMII/pHmonitoringoranempiricthreemonthtrialofvigorousacidsuppression
forpatientswitheitherofthefollowingcharacteristics,particularlyiftheylackseasonalorallergicsymptoms
[1,47]:
Nocturnalasthmamorethanonceaweek
Continuousrequirementfororalcorticosteroids,highdoseinhaledcorticosteroids,morethantwocourses
oforalcorticosteroidsperyear,orpersistentasthmathatdoesnotallowthepatienttobeweanedfrom
medicalmanagement
SimilarapproachesareusedforadultpatientswithasthmaandpossibleGERD.(See"Gastroesophagealreflux
andasthma".)
RecurrentpneumoniaGERDcanbeassociatedwithrecurrentpneumonia,especiallyinpatientswith
underlyingneurologicdysfunction,orwithanatomicalabnormalitiesthatpredisposetoaspiration,suchascleft
lip/palate,choanalatresia,ormicrognathia.Suchpatientsshouldbeevaluatedforswallowingdysfunctionusing
videofluoroscopyand/orfiberopticendoscopicevaluationofswallowing.EsophagealpHmonitoringhaslow
sensitivityandspecificityindetectingwhetheraspirationpneumoniaisrelatedtorefluxinanindividualpatient,
butmayhelpestablishthediagnosisinselectedpatientswithsuspectedaspirationwhencombinedwithother
investigations.(See"Aspirationduetoswallowingdysfunctionininfantsandchildren".)
Otherthandirectevaluationofswallowingforpatientswithsuspectedswallowingdysfunction,notechniquesare
availabletodeterminedefinitivelywhetherGERDiscausingchronicaspirationinanindividualpatient.
Measurementoflipidladenmacrophages(obtainedbybronchoalveolarlavage)andnuclearscintigraphyhave
beenusedforthispurpose,butneithertechniquecanreliablydeterminewhetherapatienthaschronic
aspiration[1].(See'Bronchoalveolarlavage'aboveand'Nuclearscintigraphy'above.)
PatientswithrecurrentpneumoniashouldalsobeevaluatedtoexcludeunderlyingcausesotherthanGERD,
includingforeignbodyaspiration,cysticfibrosis(CF),orimmunodeficiency.Ahistoryofchokingishighly
suggestiveofforeignbodyaspiration,evenifthechokingoccurreddaysorweekspriortotheonsetof
respiratorysymptoms.AnHtypetracheoesophagealfistulashouldalsobeconsideredinachildwithrecurrent
pneumonia,especiallyifthesamesegmentofthelungisalwaysinvolved.(See"Airwayforeignbodiesin
children"and"Congenitalanomaliesoftheintrathoracicairwaysandtracheoesophagealfistula",sectionon
'Tracheoesophagealfistulaandesophagealatresia'.)

ChroniccoughMostauthoritiessuggestthatGERDisnotacommoncauseofisolatedchroniccoughin
children,exceptinthosewithneurologicabnormalitiespredisposingtoaspiration,asdescribedabove.Children
withchroniccoughshouldbeevaluatedforavarietyofunderlyingcauses,includingasthma.Achronic"wet"
coughtypicallyhasanunderlyingcauseotherthanGERD,includingforeignbodyaspirationorprotracted
bacterialbronchitis.(See"Causesofchroniccoughinchildren",sectionon'Gastroesophagealreflux'and
"Approachtochroniccoughinchildren".)
OtherconditionsStridor,hoarseness,sinusitis,otitismediahavebeenassociatedwithGERD,mostlyin
casereportsandcaseseriesinchildren.NeithertheassociationwithGERnorresponsetoantisecretory
therapyhavebeenestablishedbycontrolledstudies[1].Therefore,otherpotentialetiologiesshouldbe
investigatedinpatientswiththesesymptomsorsigns.(See"Otitismediawitheffusion(serousotitismedia)in
children:Clinicalfeaturesanddiagnosis",sectionon'Pathogenesis'and"Commoncausesofhoarsenessin
children",sectionon'Gastroesophagealreflux/laryngopharyngealreflux'.)
Similarly,inthemajorityofinfantswithapneaorapparentlifethreateningevents(ALTEs),GERisnotthe
cause.InthefewcasesinwhichGERisstronglysuspectedwithrecurrentapnea,combinedMII/pHesophageal
monitoringandpolysomnographicrecordingwithsymptomdiarymayhelpestablishcauseandeffect.(See
'EsophagealpHmonitoringorimpedancemonitoring'aboveand"Acuteeventsininfancyincludingbrief
resolvedunexplainedevent(BRUE)",sectionon'Gastroesophagealrefluxorswallowingdysfunction'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.
Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.
BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticles
arewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationand
arecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Acidreflux(gastroesophagealrefluxdisease)inchildrenand
adolescents(TheBasics)")
BeyondtheBasicstopics(see"Patienteducation:Acidreflux(gastroesophagealrefluxdisease)inchildren
andadolescents(BeyondtheBasics)"and"Patienteducation:Acidreflux(gastroesophagealreflux)in
infants(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Gastroesophagealreflux(GER)iscommonininfants,asmanifestedbyregurgitation,andisgenerallynot
pathological.Theregurgitationusuallyresolvesby18monthsofage.Gastroesophagealrefluxdisease
(GERD)referstoGERthatisassociatedwithpathologicalcomplications.(See'Epidemiology'aboveand
'Definitions'above.)
Thedifferentialdiagnosisofgastroesophagealrefluxdisease(GERD)inchildrenisbroad,particularlywhen
theprincipalcomplaintisregurgitation,vomiting,orabdominalpain(table1).Thediagnosticpossibilities
canbenarrowedbasedupontheageofthechildandthepatternofsymptoms,usingathoroughmedical
history(table2).(See'History'above.)

SymptomsthatarenottypicalforGERDincludefever,weightlossorfalteringgrowth,abdominal
tendernessordistension,biliousvomiting,markedhematemesis,hepatosplenomegaly,headacheornew
neurologicsymptoms,orothersystemicsymptoms.Patientswiththesesymptomsshouldbecarefully
evaluatedforotherdisorders.(See'Recurrentvomitingorregurgitation'aboveand"Approachtotheinfant
orchildwithnauseaandvomiting".)
SymptomsthatsuggestthepossibilityofGERDinclude(see'Clinicalmanifestations'above):
Recurrentregurgitationthatcontinuesaftertwoyearsofage
Refusaloffood,especiallysolids
Frequentcomplaintsofheartburn
Dysphagia(difficultyswallowing)
Severeorprogressiveasthmathatisnotresponsivetostandardtherapyforasthma
Recurrentpneumonia,particularlyinchildrenwithneurologicdysfunction
Chronichoarsenessorstridor
Whenchildrenpresentwiththesesymptoms,furtherworkupisappropriate.(See'Suggestedapproachfor
commonclinicalscenarios'above.)
Theevaluationshouldincludeassessmentforthepossibilityofoccultorassociatedconstipation,since
constipationcausessecondaryrefluxordyspepticsymptomsinmanychildren.(See'History'aboveand
"Constipationininfantsandchildren:Evaluation".)
Forpatientspresentingwithmildormoderatesymptomsofheartburn,initialempirictreatmentwithacid
suppressingdrugsisreasonable.Persistentorrecurrentsymptomsshouldpromptreferralforanupper
endoscopywithbiopsy,especiallyifanydysphagiaispresent.(See'Empirictreatment'above.)
Endoscopicevaluationoftheuppergastrointestinaltractisindicatedforpatientswithheartburnor
epigastricabdominalpainthatfailstorespondtoorrelapsesquicklyafterempirictreatment,orthosewith
dysphagiaorodynophagia.Inaddition,endoscopymaybevaluableintheevaluationofpatientswho
continuetohaverecurrentregurgitationaftertwoyearsofage.(See'Suggestedapproachforcommon
clinicalscenarios'aboveand'Endoscopyandhistology'above.)
Endoscopicevaluationisnecessarytoestablishthediagnosisofesophagitis.Mostesophagitisisrelatedto
GERD,buteosinophilicesophagitisisincreasinglyrecognized.Treatmentofesophagitisisdiscussed
separately.(See'Endoscopyandhistology'aboveand"Clinicalmanifestationsanddiagnosisofeosinophilic
esophagitis"and"Managementofgastroesophagealrefluxdiseaseinchildrenandadolescents".)
EvaluationwithesophagealpHmonitoringormultichannelintraluminalimpedancemonitoring(MII),
bronchoalveolarlavage,nuclearscintigraphy,oresophagealmanometryisonlyusefulinspecificclinical
situations,anddoesnotgenerallycontributetothediagnosisofachildwithtypicalheartburn.Barium
contrastradiographyisneithersensitivenorspecificforthediagnosisofGERD,butmaybeusedin
selectedpatientstoexcludeanatomicabnormalities.(See'Availablediagnostictechniques'aboveand
'History'above.)
Insomepatients,GERmaybeatriggerforasthma.Therefore,inpatientswithsevereorrefractoryasthma,
orthosewithfrequentnocturnalasthma,anempirictrialofeffectiveacidsuppressionisappropriate.(See
'Asthma'aboveand"Gastroesophagealrefluxandasthma".)

Childrenwithdysphagiashouldhaveabariumesophagramtoevaluateformotilitydisorders,inflammatory
stricturesandanatomiccausesofthesymptomsupperendoscopymayalsobehelpfulindiagnosing
esophagitis.Inchildrenwithodynophagia(painfulswallowing),diagnosticendoscopyshouldbeperformed
ratherthanempirictreatmentwithacidsuppressionduetothepossibilityofinfectiousesophagitis.An
esophagealmotilitystudyishelpfulindiagnosingprimarymotilitydisorderssuchasachalasia.(See
'Dysphagiaorodynophagia'above.)
Inmostchildrenwithstridor,hoarseness,sinusitis,otitismedia,andapnea,GERisnotthecause.
Therefore,otherpotentialetiologiesshouldbeconsideredinpatientswiththesesymptomsorsigns.Inthe
fewcasesofsuspectedGERassociatedwithrecurrentapnea,esophagealmonitoringusingcombined
multichannelintraluminalimpedanceandpH(MII/pH)andpolysomnographicrecordingmayhelpestablish
causeandeffect.(See'Otherconditions'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic5892Version25.0