Pediatric Nutrition in Practice

Regurgitation and Gastroesophageal Reflux 205

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identify ‘red f lags’ which may indicate the need
for a different or accelerated approach ( table  2 ).
The history should take into account the patient’s
age, birth history, allergies and development, as
well as the feeding history and temporal relation-
ship of symptoms to meals. In the case of infan-
tile and childhood ref lux, however, the history is
neither sensitive nor specific enough to be credi-
bly relied on for a diagnosis of GERD. This was
demonstrated by Orenstein et al. [7] , who at-
tempted to treat infants with a history suggestive
of GERD with proton pump inhibitors (PPI) or
placebo. Both arms of the study responded simi-
la rly. T his wou ld seem to i nd icate t hat t he histor y
alone is not able to identify which patients have
GERD as a cause of their symptoms, and which
have other etiologies with similar presentations
(e.g. infantile colic and cow’s milk protein aller-
gy). Furthermore, the study indicates that a PPI
test in which the drug may be given for a limited
time is also inaccurate.

Historically, patients were often sent to per-

form barium swallows to diagnose reflux; how-

ever, the test should not be used for this indica-

tion because it has both low sensitivity and spec-

ificity, not to mention the significant radiation

exposure involved. Esophago-gastro-duodenos-

copy allows for visualization of damage caused

to the esophageal mucosa by acid reflux as well

as direct tissue sampling, which may also aid in

the identification of other conditions that may

present diagnostic challenges (e.g. eosinophilic

esophagitis, allergic gastritis and inflammatory

bowel disease). However, esophago-gastro-duo-

denoscopy is neither able to identify nonerosive

GERD nor to directly demonstrate ref lux but

rather only its consequences.

Prolonged esophageal pH monitoring, in

which a pH-sensitive probe is placed in the lower

esophagus and left for 24 h, allows for direct dem-

onstration of esophageal acid, although it cannot

differentiate swallowed from regurgitated acid.

Ta b l e 1. Signs and symptoms of GER and GERD

Infants Older children Extraesophageal signs

Recurrent spitting up/vomiting Heartburn Treatment-resistant asthma

Poor weight gain Substernal pain Dental erosion

Feeding refusal Water brash Recurrent pneumonia

Irritability Nausea Hoarseness

Back arching Epigastric abdominal pain Chronic cough

Apnea/bradycardia Recurrent vomiting

Ta b l e 2. Warning signs that may warrant further investigation

Persistent forceful vomiting

Bilious vomiting

Gastrointestinal bleeding

Late onset (>6 months)

Failure to thrive

Repeated choking or episode of apparent life-threatening event

Constipation

Bulging fontanel, seizures or new neurological deficits

Family history of genetic or metabolic disorder

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