Regurgitation

From the 2018 NASPGHAN Guidelines:

Diagnostic approach of infants (age 0–12 months) with frequent regurgitation and/or vomiting

In the infant with recurrent regurgitation or spitting, a thorough history (Table 1) and physical examination with attention to warning signals suggesting other diagnoses (Tables 1, 3) is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER (Algorithm 1).

The history should include the age of onset of symptoms, a thorough feeding and dietary history, the pattern of regurgitation/spitting/vomiting, a family medical history, possible environmental triggers (including family psychosocial history and factors such as tobacco use and second-hand tobacco-smoke exposure), the patient’s growth trajectory, prior pharmacologic and dietary interventions, and the presence of warning signs (Table 2). Physiologic GER seldom starts before the age of 1 week or after the age of 6 months. While GER is benign in the vast majority of children, some children merit additional testing. The working group recognizes that there are occasions where GER symptoms may be considered harmful or bothersome when the onset, volume, force or frequency symptoms fall outside the expected parameters and therefore sometimes merit further investigation or treatment. In these cases, patients may no longer be classified as having GER but rather GERD. In the presence of ‘red flags’ (Table 2), conditions other than GERD may be more likely (differential diagnosis of GERD, Table 3). The diagnostic approach of infants with frequent regurgitation or vomiting is presented in Algorithm 2.

Diagnostic approach of children (age 12 months to 18 years) with frequent regurgitation and/or vomiting

Physiologic regurgitation and episodic vomiting are frequent in infants. Onset of GERD symptoms after the age of 6 months as well as persistence of symptoms beyond 12 months old raises the possibility of alternative diagnoses to infant GER. Because these symptoms are not unique to GERD, referral to a pediatric gastroenterologist for evaluation to diagnose possible GERD and to rule out other diagnoses is recommended based on expert opinion. The goal of additional testing is to rule out mimickers or complications of GERD. Testing may include laboratory tests, contrast imaging, upper GI endoscopy and/or esophageal pH/MII, depending on presenting symptoms (Tables 2 and 3). The diagnostic approach of children with frequent regurgitation or vomiting is presented in Algorithm 2.