The symptoms of gastroesophageal reflux are most often directly related to the consequences of emesis (poor weight gain) or result from exposure of the oesophageal epithelium to the gastric contents.

In paediatric gastro-oesophageal reflux disease (GORD or GERD), immaturity of lower oesophageal sphincter function is manifested by frequent transient lower esophageal relaxations, which result in retrograde flow of gastric contents into the oesophagus

The typical adult symptoms (heartburn, vomiting, regurgitation) cannot be readily assessed in infants and children. Paediatric patients with GORD typically cry and show sleep disturbance and decreased appetite. Other common signs and symptoms in infants and young children include the following:

  • Typical or atypical crying and/ or irritability
  • Apnea and/or bradycardia
  • Poor appetite; weight loss or poor growth (failure to thrive)
  • Apparent life-threatening event
  • Vomiting
  • Wheezing, stridor
  • Abdominal and/or chest pain
  • Recurrent pneumonitis
  • Sore throat, hoarseness and/or laryngitis
  • Chronic cough
  • Water brash
  • Sandifer syndrome (i.e, posturing with opisthotonus or torticollis).
  • Signs and symptoms in older children include all of the above plus heartburn and a history of vomiting, regurgitation, unhealthy teeth, and halitosis.


Regurgitation of food, one of the most common presenting symptoms in children, ranges from drooling to projectile vomiting. Most often, regurgitation is postprandial, although delays of 1-2 hours occur. One must also consider anatomic anomalies and protein allergy in a vomiting child, as well as inborn metabolic disorders (rare).

Physical exam

No classic physical signs of gastrooesophageal reflux are recognised in the paediatric population (although an infant or toddler arriving in the office wearing a bib is often a sure tip off). One exception would be the relatively uncommon Sandifer syndrome, which is often misdiagnosed as spastic torticollis. In toddlers and older children, excessive regurgitation may lead to significant dental problems caused by acid effects on tooth enamel. In the vast majority of cases, a diagnosis of GORD is typically made once the primary care provider has obtained a clinical history that suggests this disorder. Oesophagitis may manifest as crying and irritability in the nonverbal infant. Failure to thrive can result from insufficient caloric intake secondary to repeated vomiting and nutrient losses from emesis. Hiccups, sleep disturbances, and Sandifer syndrome (arching) have also been shown to be associated with gastro- oesophageal reflux and esophagitis.


Most cases of paediatric gastrooesophageal reflux are diagnosed based on the clinical presentation. Conservative measures can be started empirically. However, if the presentation is atypical or if therapeutic response is minimal, further evaluation via imaging is warranted. There are no recognised classic physical signs of gastrooesophageal reflux in the pediatric population. Some findings may include the following:

  • Nonverbal infant: Crying and irritability, failure to thrive, hiccups, sleep disturbances, Sandifer syndrome (arching)
  • Toddlers and older children: Significant dental problems from excessive regurgitation, causing acid effects on tooth enamel.