What are the signs, symptoms, and treatment options for pediatric patients with gastroesophageal reflux disease (GERD)?

Signs and Symptoms of Pediatric Gastroesophageal Reflux

Age-Specific Clinical Presentations

Infants (Under 12 Months)

The most common symptoms in infants include regurgitation or vomiting, irritability, feeding refusal or anorexia, poor weight gain, sleep disturbance, and respiratory symptoms such as coughing, choking, or wheezing 1. These symptoms typically begin before 8 weeks of life, peak at approximately 4 months, and resolve spontaneously by 12 months in 95% of cases 2, 3.

• Regurgitation and vomiting are the predominant manifestations, occurring daily in approximately 40% of infants 2, 3
• Irritability coupled with back arching is considered the non-verbal equivalent of heartburn in older children 2
• "Happy spitters" describe infants with physiologic reflux who are thriving and asymptomatic despite frequent regurgitation 2
• Feeding difficulties including choking, gagging, or coughing during feeds may indicate GERD rather than simple reflux 2

Children (1-11 Years)

In children aged 1 to 11 years, symptoms mirror adult presentations more closely, with abdominal pain, recurrent vomiting, and feeding difficulties being most common 4, 1.

• Abdominal pain or heartburn becomes a more prominent complaint as children can verbalize discomfort 4
• Recurrent vomiting without other explanation 4
• Dysphagia may indicate esophageal complications 4
• Respiratory manifestations including asthma, recurrent pneumonia, chronic cough, and hoarseness 4

Adolescents (12-17 Years)

Adolescents present with adult-like symptoms, predominantly heartburn and regurgitation 4, 5.

• Heartburn is the hallmark symptom in this age group 6
• Abdominal pain or epigastric discomfort 4
• Recurrent vomiting 4
• Upper airway symptoms including chronic cough and hoarseness 4

Warning Signs Requiring Urgent Evaluation

The presence of any warning signs mandates immediate investigation for serious underlying conditions beyond simple GERD 4, 1.

Critical red flags include:

• Bilious vomiting - suggests intestinal obstruction distal to the ampulla of Vater, including malrotation or duodenal web 4, 1, 7
• Consistently forceful or projectile vomiting - particularly concerning for pyloric stenosis in infants 2-8 weeks of age 4, 7
• Gastrointestinal bleeding including hematemesis or hematochezia 4, 1
• Fever or lethargy 4, 1
• Hepatosplenomegaly 4, 1
• Bulging fontanelle, macro/microcephaly, or seizures 4, 1
• Abdominal tenderness or distension 4, 1
• Documented or suspected genetic/metabolic syndrome 4
• Associated chronic disease 4

Diagnostic Approach

For most pediatric patients without warning signs, a thorough history and physical examination are sufficient to diagnose uncomplicated GERD and initiate treatment without diagnostic testing 4, 1.

When to Consider Diagnostic Testing

Diagnostic studies should be reserved for specific scenarios 4:

• Presence of warning signs requiring exclusion of serious pathology 1
• Diagnostic uncertainty when symptoms are atypical 4
• Treatment failure after appropriate empiric therapy 4
• Suspected complications such as esophageal stricture or severe esophagitis 4

Available Diagnostic Modalities

• Upper GI series: Useful for evaluating anatomic abnormalities (malrotation, pyloric stenosis) but NOT recommended for routine GERD diagnosis as studies are too brief and lead to false-positive diagnoses 4, 1
• Esophageal pH monitoring: Quantifies acid exposure and correlates symptoms with reflux episodes 4
• Upper endoscopy with biopsy: The primary method to evaluate for esophageal injury, exclude other conditions mimicking GERD, and differentiate erosive from non-erosive disease 4
• Multichannel intraluminal impedance: Detects both acid and non-acid reflux episodes 4

Validated Assessment Tools

The Kleinman questionnaire is validated for documenting and monitoring parent-reported GERD symptoms in infants 1. For children 7-16 years, the Størdal questionnaire correlates well with pH monitoring results 4.

Common Clinical Pitfalls

Avoid over-diagnosing GERD in "happy spitters" - infants with frequent regurgitation but normal growth and no distress require only parental reassurance, not treatment 2, 3.

• Do not routinely order upper GI series for GERD diagnosis, as this leads to false-positive results and unnecessary interventions 4, 1
• Consider cow's milk protein allergy in the differential, as it co-exists with GERD in 42-58% of infants and symptoms overlap significantly 2
• Recognize that symptoms alone may not resolve with acid-suppression therapy, particularly if the underlying diagnosis is not GERD 1
• Evaluate for pyloric stenosis with ultrasound (not upper GI series) when persistent forceful vomiting occurs in the first few months of life 4, 7

Special Populations at Higher Risk

Children with neurologic impairment, obesity, history of esophageal atresia, and chronic respiratory disorders face increased risk for severe GERD and complications 6.