How Does Gastroesophageal Reflux Present?

Patient Presentation
A 4-month-old female came to clinic because her parents were concerned about frequent spitting up.
They reported spitting up of at least 1/4 of her formula with feeding that was associated with her arching or crying. She seemed eager to eat, but part way through or after the feeding she would become fussy, have some spitting up of formula only, and arch her body. She would finish her formula and was fussy for a period of time after the feeding.
This pattern occurred at least 2-4 times/day. The spitting up was never projectile. She was taking about 30 ounces of formula per day (5-6 ounces every 4 hours). Frequent burping and a change from a cows milk-based formula to a soy-based formula did not improve the symptoms.
During the interview her mother did feed her and the infant was noted to be fussy and effortlessly spit up at least 1 ounce of formula but did not arch.
The past medical history revealed a full-term infant with no prenatal or natal complications.
The family history was positive for her mother having severe heartburn that she is followed for by a specialist. The father was described as having a sensitive stomach.
The review of systems was negative for choking, coughing, apnea or gastrointestinal complaints including blood in the stool or vomitus. She had normal growth and development to date.
The pertinent physical exam showed an infant that interactively smiled initially. Her growth parameters were 10-50% for height, weight and head circumference and were tracking correctly on the growth charts.
Her gastrointestinal examination revealed a soft abdomen with no tenderness, hepatosplenomegaly or masses.
The clinical diagnosis of gastroesophageal reflux disease was made and the patient was begun on lansoprazole (off-label use of a gastric acid pump inhibitor) empirically.
The patient’s clinical course showed that within a few days the episodes had stopped and the infant continued to be evaluated by telephone and electronic mail. The lansoprazole was continued and at ~ 7 months of age, the mother called because the symptoms had re-appeared.
The dosage was increased based upon a more recent weight and the symptoms again went away. At the 9 month visit, the physician and parents agreed to an empirical trial off the medication to see if it was still needed.

Gastroesophageal reflux (GER) is the normal physiological process of gastric contents passing into the esophagus throughout the day that is caused by transient relaxation of the lower esophageal sphincter.
This is usually cleared by gravity, peristasis and neutralization of the acid by saliva. These protective mechanisms decrease during sleep.
This process can sometimes lead to gastroesophageal reflux disease (GERD).
Since GER is normal, it can be difficult sometimes to determine if there is GERD. There is no gold standard for GERD diagnostic testing, but common tests include:

  • Upper gastrointestinal radiography (UGI) is useful to determine anatomical abnormalities and other causes of nonbilious emesis such as pyloric stenosis and achalasia. Reflux of radiographic contrast occurs in many normal individuals and therefore UGI is not useful for GERD.
  • Esophageal pH monitoring. Monitoring records the frequency and duration of reflux episodes into the esophagus. Certain standard measurements (11% mucosal exposure for infants and 6% for older children) determine the risk for esophagitis.
  • Upper endoscopy with biopsy – is useful to evaluate for esophagitis, stricture, etc. Also allows diagnosis of other diseases (e.g. Crohn’s disease).
  • Nuclear scintigraphy – monitors the distribution of radiolabeled food, but reflux of the food can occur in normal individuals.

Warning signs and symptoms of disorders other than GERD include:

  • Abdominal distension or tenderness
  • Bilious or forceful emesis
  • Constipation
  • Diarrhea
  • Fever
  • Fontanelle bulging
  • Hepatosplenomegaly
  • GI bleeding
  • Lethargy
  • Macro- or microcephaly
  • Onset of emesis after 6 months of age
  • Seizures

Learning Point
Common presentations of gastroesophageal reflux include:

  • General
    • Arching of the body or posturing (i.e. Sandifer syndrome)
    • Fussiness, irritability, inconsolable crying
    • Halitosis
    • Poor dentitia
    • Weight loss, failure to gain adequate weight, or failure to thrive
  • Gastrointestinal
    • Chest pain or abdominal pain (heartburn)
    • Dysphagia
    • Non-forceful, non-bilious emesis
    • Melena, anemia
    • Sore throat
  • Pulmonary
    • Apnea, sudden infant death syndrome, acute life threatening event
    • Bronchospasm, wheezing, asthma
    • Cough
    • Hoarseness
    • Laryngitis
    • Stridor
    • Recurrent pneumonia or pulmonary fibrosis

Questions for Further Discussion
1. What does off-label use of a drug mean?
2. What are the potential legal implications of using a drug off-label?
3. What treatments are used for GERD?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: GERD and Heartburn
and at Pediatric Common Questions, Quick Answers for this topic: Heartburn

To view current news articles on this topic check Google News.

Liburd JDA, Hebra A. Gastroesophageal Reflux. eMedicine.
Available from the Internet at (rev. 02/15/2005, cited 9/19/2006).

Rudolph CD, Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1389-1394.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    October 16, 2006