Esophageal Stricture from Chronic GERD
This infant is at risk of developing esophageal stricture as a complication of untreated gastroesophageal reflux disease (GERD). The clinical presentation—six months of inconsolable crying, feeding refusal, coughing and choking during feeds, and recurrent otitis media—is classic for GERD with esophagitis in infancy 1, 2, 3.
Why Esophageal Stricture is the Primary Risk
GERD with esophagitis is the underlying diagnosis based on the constellation of feeding refusal (suggesting odynophagia from esophageal inflammation), coughing/choking during feeds (aspiration from reflux), and chronic irritability 1, 2.
Esophageal stricture develops in 5% of infants with refractory esophagitis who have prolonged acid exposure causing chronic mucosal inflammation and subsequent fibrosis 4.
The six-month duration with worsening symptoms over the past month indicates progressive disease that has not spontaneously resolved, placing this infant in the high-risk category for complications 4.
Feeding refusal itself is a red flag for esophagitis, as infants learn to refuse food when swallowing causes pain (odynophagia), creating a vicious cycle that can lead to failure to thrive and persistent esophageal injury 2, 3.
Clinical Evidence Supporting GERD Diagnosis
Troublesome symptoms in this age group include feeding refusal, recurrent vomiting, irritability, and respiratory symptoms—all present in this case 1.
The association with recurrent otitis media is well-established, as GERD and otitis media frequently coexist due to shared pathophysiology involving eustachian tube dysfunction from refluxate 1.
Coughing and choking during feeding suggest aspiration or laryngospasm triggered by reflux, which can lead to airway obstruction 1.
Peak incidence of GERD is at 4 months of age, and this 6-month-old with persistent symptoms beyond the typical resolution period (3-6 months) requires urgent evaluation 1, 5.
Why Other Options Are Incorrect
Pyloric stenosis presents with projectile vomiting in the first 2-6 weeks of life, not at 6 months with a chronic course [@general medical knowledge].
Malrotation typically presents acutely with bilious vomiting and signs of intestinal obstruction, not chronic feeding difficulties [@general medical knowledge].
Intestinal atresia is a congenital anomaly presenting in the immediate newborn period with complete feeding intolerance and abdominal distension [@general medical knowledge].
Immediate Management Algorithm
Upper endoscopy with esophageal biopsy is the primary diagnostic method to evaluate for GERD-related esophageal injury and exclude stricture formation 1.
Do NOT perform routine upper GI series, as the brief observation period is inadequate to rule out pathologic reflux, and the high prevalence of nonpathologic reflux leads to false-positive diagnoses [@1@].
Esophageal pH monitoring with impedance should be considered if endoscopy is negative but clinical suspicion remains high 1.
Feeding evaluation by speech therapy is essential to assess for poor suck-swallow-breathe coordination that may be contributing to aspiration 1.
Treatment Priorities
Acid suppression therapy with proton pump inhibitors is indicated when esophagitis is documented on endoscopy, as this infant has troublesome symptoms meeting GERD criteria 1.
Conservative measures alone are insufficient given the six-month duration and worsening symptoms—this infant needs pharmacologic intervention [1, @15@].
Thickened feeds and upright positioning should be implemented immediately while awaiting endoscopy [@2@, @11@].
Monitor for failure to thrive, as 18% of infants with GERD develop growth failure requiring aggressive nutritional intervention [@15@].
Critical Pitfalls to Avoid
Delaying endoscopy in infants with feeding refusal and chronic symptoms leads to missed esophagitis and progression to stricture, which occurred in 5% of cases in one series [@15@].
Dismissing symptoms as "colic" when the infant is 6 months old (beyond typical colic resolution at 3-6 months) delays diagnosis of serious pathology [@12@, 4].
Failing to recognize that "silent reflux" without visible regurgitation can still cause severe esophagitis and complications [@11@].
Not addressing maternal distress and feeding dynamics, as GERD significantly impairs mother-child feeding interactions and can escalate to child abuse in severe cases [@13