What are Signs / Symptoms of
Gastroesophageal Reflux (GER) in the Neonate?
Gastroesophageal reflux (GER), which is the passage of gastric
contents into the esophagus, is a common problem for newborn
infants, as well as premature infants in the NICU setting. Since
the signs, symptoms, treatments, and co-morbidities vary widely
from the premature to the healthy term infant, we have focused this
EBP review and algorithm on the premature infant in the NICU
GER is very common in healthy infants, as gastric fluids reflux
into the esophagus multiple times each day. It appears that GER is
more common in healthy preterm infants, as compared to term
infants. The pathogenesis of GER is multifactorial, with the most
important etiology being the transient relaxation of the lower
Controversy remains as to the severity of the disease and what,
if any, treatment should be attempted for GER. Convincing studies
are difficult to perform, which has further contributed to the
variation in clinical practice. (Vandenplas et al, 2009)
In the NICU setting, apnea and bradycardia events are often
thought to be caused by GER. Many studies in premature infants have
been performed, which have failed to demonstrate a temporal
relationship between GER and apnea. Hence, this EBM review and
algorithm will not address this topic.
Premature infants and chronically ill infants appear prone to GE
reflux and the complications that can arise due to GE reflux.
- Gastroesophageal reflux in the neonate occurs in 22-85% of
preterm infants (Tipnis & Tipnis, 2008).
- Twenty five percent of very low birthweight infants are treated
with acid suppression therapy at discharge (Tipnis & Tipnis,
- In term infants, vomiting is a common symptom of
gastroesophageal reflux and recurrent vomiting occurs in 50% of
infants from 0-3 months, 67% in four month old infants and 5% in
10-12 month old infants (Bhatia & Parish, 2009).
- Intracranial hemorrhage
- Intracranial mass
- Infant migraine
- Chiari malformation
- Urinary tract infection
- Otitis media
- Hereditary fructose intolerance
- Urea cycle defects
- Amino and organic acidemias
- Congenital adrenal hyperplasia
- Obstructive uropathy Renal insufficiency
- Vitamins A and D
- Medications-ipecac, digoxin, theophylline, etc
- Congestive heart failure
- Vascular ring
- Pediatric falsification disorder (Munchausen syndrome by
- Child neglect or abuse
- Self-induced vomiting
- Cyclic vomiting syndrome
- Autonomic dysfunction
These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.
It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.