History
The symptoms of gastroesophageal reflux are most often directly related to the consequences of emesis (eg, poor weight gain) or result from exposure of the esophageal epithelium to the gastric contents.
One must remember that the typical symptoms (eg, heartburn, vomiting, regurgitation) in adults cannot be readily assessed in infants and children. Pediatric patients with gastroesophageal reflux typically cry and report sleep disturbance and decreased appetite. The following are some of the common signs and symptoms of gastroesophageal reflux in infants and young children:
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Typical or atypical crying and/or irritability
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Apnea and/or bradycardia
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Poor appetite
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Apparent life-threatening event (ALTE)
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Vomiting
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Wheezing
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Abdominal and/or chest pain
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Stridor
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Weight loss or poor growth (failure to thrive)
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Recurrent pneumonitis
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Sore throat
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Chronic cough
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Water brash
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Sandifer syndrome - Ie, posturing with opisthotonus or torticollis
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Hoarseness and/or laryngitis
Signs and symptoms in older children include all of the above plus heartburn and a history of vomiting, regurgitation, unhealthy teeth, and halitosis.
ALTEs
ALTEs that involve apnea associated with bradycardia, pallor, and/or cyanosis have been linked to gastroesophageal reflux, especially in premature infants. In these events, reflux into the hypopharynx is postulated to lead to laryngospasm and subsequent obstructive apnea. However, data suggest only a weak association between these phenomena. Any such relationship can be objectively determined only by esophageal pH monitoring or, preferably, by esophageal multichannel intraluminal impedance testing, performed in conjunction with pneumography and either nasal thermistor or pulse oximetry recording.
Regurgitation
Regurgitation of food, one of the most common presenting symptoms in children, ranges from drooling to projectile vomiting. Most often, regurgitation is postprandial, although delays of 1-2 hours occur. One must also consider anatomic anomalies and protein allergy in a vomiting child, as well as inborn metabolic disorders (rare).
Bronchial and other symptoms
Some patients have atypical symptoms (eg, nocturnal cough, wheezing, or hoarseness as the only major complaint). Gastroesophageal reflux is a complicating factor in asthma. The mechanism may include microaspiration, which leads to reflex bronchoconstriction. The association of gastroesophageal reflux and airway or respiratory tract disease is common. Cough, stridor, and pharyngitis have all been linked to gastroesophageal reflux. In addition, an association with rumination is commonly observed in patients with developmental delay.
Physical Examination
No classic physical signs of gastroesophageal reflux are recognized in the pediatric population (although an infant or toddler arriving in the office wearing a bib is often a sure tip off). One exception would be the relatively uncommon Sandifer syndrome, which is often misdiagnosed as spastic torticollis.
In toddlers and older children, excessive regurgitation may lead to significant dental problems caused by acid effects on tooth enamel. In the vast majority of cases, a diagnosis of gastroesophageal reflux is typically made once the primary care provider has obtained a clinical history that suggests this disorder.
Esophagitis may manifest as crying and irritability in the nonverbal infant. Failure to thrive can result from insufficient caloric intake secondary to repeated vomiting and nutrient losses from emesis. Hiccups, sleep disturbances, and Sandifer syndrome (arching) have also been shown to be associated with gastroesophageal reflux and esophagitis.
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The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
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Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).
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Illustration of the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360-degree wrap).
