Pediatric Nutrition in Practice

204 Zevit  Shamir

In infancy, regurgitation may not appear im-
mediately after birth and becomes more common
in the first months of life, peaking at approxi-
mately 4–5 months, at which time nearly 40% of
infants regurgitate more than once daily ( fig. 1 )
[5]. Thereafter there is a gradual decrease in prev-
alence, such that by around 18 months of age, re-
flux has resolved in the vast majority of cases.
The remaining patients generally warrant inves-
tigation even if the regurgitation remains asymp-
tomatic.

Signs and Symptoms

The clinical presentation of GER and GERD
ranges across a spectrum of signs and symptoms
which may vary with age and can include both
esophageal and extraesophageal symptoms ( ta-
ble 1 ) [1]. In infants, the most common presenta-
tion is that of a well-thriving, regurgitating baby
(the ‘happy spitter’). In most cases of GER, the
child has no symptoms or distress. GER may at
times be associated with a vomiting reflex. As
GER in infants and young children progresses to
GERD, fussiness at times of eating or following
meals, food refusal with subsequent poor weight
gain, arching of the back with turning of the head,
coined Sandifer syndrome (which at times can

appear seizure-like or be mistaken for torticollis),

and excessive crying may be seen, though none of

these are specific. Apnea and bradycardia are

rare.

Older children and adolescents may present

with frank regurgitation, and heartburn, noncar-

diac chest pain and epigastric abdominal pain

may be present [6]. Chronic iron deficiency ane-

mia may indicate erosive esophagitis. Extrae-

sophageal manifestations ( table 1 ) become more

prevalent in older children and adolescents.

Longstanding ref lux may lead to peptic strictures

inducing dysphagia and even food impaction.

Furthermore, chronic reflux is associated with

Barrett’s esophagus.

D i a g n o s i s

Currently, no diagnostic test exists which can be

considered a gold standard for the diagnosis of

GERD and which can adequately differentiate

between physiological and pathological signs

and symptoms throughout the spectrum of pre-

sentations. As such, there are several diagnostic

methods which may be utilized in an investiga-

tion.

A thorough history and physical examination

can aid in the diagnosis of GERD and help to

45

40

35

30

25

20

15

10

5

0

123 45 678 910111213

Age (months)

Infants (%)

1415161718192021222324

Fig. 1. Proportion of infants regurgi-
tating most feeds. Reproduced and
adapted with permission from Mar-
tin et al. [5].

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 203–208

DOI: 10.1159/000360341