Gastroesophageal Reflux in Infants

Definition and Epidemiology

• Gastroesophageal reflux is a physiological process in infants, characterized by the retrograde passage of gastric content into the esophagus, generally without force, and is most common at 4 months (50%) and decreases to 5-10% by 1 year of age, with spontaneous resolution in 95% of infants by 1 year, according to the American College of Radiology and supported by the British Medical Journal guidelines and the American Academy of Pediatrics 1, 2, 3
• The incidence of GER at different ages is summarized in the following table:

2, 3

Diagnosis and Evaluation

• The American Academy of Pediatrics recommends against routine ordering of upper GI studies for diagnosing reflux due to their low sensitivity and specificity 4
• For infants under 12 months without alarm signs, no investigation is required, and management involves parental reassurance and education, as recommended by the National Institute for Health and Care Excellence and the American Academy of Pediatrics 2, 3
• The American College of Radiology recommends evaluating for alarm signs, including bilious or bloody vomiting, projectile vomiting, abdominal distension, failure to thrive, difficulty feeding or swallowing, persistent irritability, abnormal postures, respiratory complications, and apnea 1
• Initial evaluation should include upper GI tract contrast radiography and consideration of esophageal pH monitoring and/or impedance monitoring for persistent symptoms, as suggested by the American Academy of Pediatrics 3
• Further investigation with upper endoscopy with esophageal biopsy, evaluation for aspiration, and assessment of immunologic competency may be necessary if symptoms persist or are severe, as recommended by the American College of Chest Physicians 5

Management and Treatment

• For uncomplicated reflux, parental reassurance and education are usually sufficient, and acid suppression therapy is not recommended, according to the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition 4
• Dietary modifications, such as a maternal exclusion diet (milk and eggs) for 2-4 weeks in breastfed infants or extensively hydrolyzed formula in formula-fed infants, may be considered, as suggested by the American Academy of Pediatrics 3
• Postural modifications, including elevating the head of the bed for patients with nocturnal symptoms and avoiding sitting or supine positions immediately after meals, are recommended by the American Gastroenterological Association and the American Academy of Pediatrics 6, 3
• Other measures, such as reducing feeding volume and increasing frequency, and avoiding overfeeding, are also recommended by the American Academy of Pediatrics 3
• Acid suppressive therapy is not recommended for uncomplicated reflux, as stated by the American Gastroenterological Association and supported by the British Medical Journal and the American Academy of Pediatrics 6, 2, 3
• In cases of confirmed gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) are more effective than H2 antagonists, according to the American Gastroenterological Association 6
• Antiemetics, such as 5-HT3 antagonists (ondansetron), dopaminergic antagonists (domperidone), and NK-1 antagonists, may be considered for nausea and vomiting, as recommended by the American Gastroenterological Association 7

Complications and Red Flags

• Reflux that presents with bilious or bloody vomiting, projectile vomiting, abdominal distension, failure to thrive, difficulty feeding or swallowing, persistent irritability, abnormal postures, or respiratory complications warrants investigation, as recommended by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition 4
• Persistent vomiting beyond 12-18 months warrants investigation even without alarm signs, as recommended by the American Academy of Pediatrics 3
• Cyclical vomiting syndrome and cannabinoid hyperemesis syndrome must be differentiated from gastroparesis with predominant nausea/vomiting, according to the American Gastroenterological Association 7

Special Populations

• Neurologically impaired children, premature infants, children with certain genetic disorders, history of esophageal atresia, and chronic respiratory disorders require earlier and more thorough evaluation, according to the American Academy of Pediatrics 4, 3
• Infants with abnormal neurological development, prematurity, or specific genetic disorders require earlier and more thorough evaluation, as noted by the American Academy of Pediatrics 3
• Certain pediatric populations, such as neurologically impaired children, patients with certain genetic disorders, children with a history of esophageal atresia, premature infants, and children with chronic respiratory disorders, require earlier and more thorough investigation, as noted by the American Academy of Pediatrics 3