When a Referral Is Indicated

Consider referral to a pediatric gastroenterologist or other pediatric subspecialist when:

• Onset of GER symptoms first occurs after 6 months of age or when symptoms persist beyond 12 months. This raises the possibility the symptoms are not due to benign GER of infancy and alternative diagnoses and/or therapy need to be considered.
• The presumed GERD signs and symptoms have not resolved or significantly improved after nonpharmacological lifestyle changes in an infant, and/or after 4 to 8 weeks of PPI pharmacological therapy with an older child or adolescent.
• The patient has a significant complication of GERD. Complications might include anemia, hematemesis, persistent nighttime awakening due to heartburn, noncardiac chest pain, regurgitation, and failure to thrive, as well as severe respiratory or upper airway (ie, otolaryngological) symptoms.
• The primary care physician believes the diagnosis is something other than reflux, based on red flag symptoms or lack of improvement.
• The infant or child displays alarm signs or symptoms suggesting an underlying gastrointestinal disease (see Table 3).
• Patients cannot be permanently weaned from pharmacological treatment within 6–12 months.