University of Virginia Health System

Gastroesophageal Reflux in Infants

Barium swallow or Upper GI series

Most of the time, just hearing the parents' story and seeing the child is enough to make the diagnosis, but sometimes testing may be recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• barium swallow or upper GI series
• technetium gastric emptying study
• pH probe
• endoscopy with biopsies
• summary

Barium swallow or Upper GI series

This is a special x-ray that allows doctors to follow food down the baby's esophagus, through the stomach and into the first part of the small intestine. The baby is fed a chalky-white liquid called barium. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract. This x-ray test does not, however, give doctors much information on how the intestine works when food is in it and therefore it is not a very reliable way of diagnosing gastroesophageal reflux.

Many children with severe symptoms of gastroesophageal reflux will not demonstrate reflux on a barium swallow (poor sensitivity) and conversely, children who demonstrate reflux on a barium swallow have no symptoms of gastroesophageal reflux (poor specificity). Perhaps more important, the severity of reflux observed on a barium swallow does not help to predict the severity of symptoms of reflux nor does it help to predict the ultimate outcome. Less than 30% of adults with symptoms of chronic gastroesophgeal reflux demonstrate reflux on a barium swallow and less than 30% of adults with esophagitis as a result of chronic gastroesophageal reflux will demonstrate reflux on a barium swallow.

Technetium reflux scan

With this test, the infant drinks milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a particular type of camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in an infants stomach.

pH Probe

With this test, a small wire with an acid sensor is placed through the infants nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is "refluxed" into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, you are able to determine how often the infant "refluxes" acid into his or her esophagus and whether he or she has any symptoms when that occurs.

The biggest problem with this test is that the severity of the reflux as measured by pH probe often doesn't correlate with the severity of symptoms . . . that is, some of infants with very frequent vomiting will have normal pH probe studies. Perhaps more important, the severity of reflux measured by a pH probe does not help to predict the ultimate outcome. While pH probe analysis is abnormal in nearly 80% of infants with mild symptoms of reflux (i.e. occasional spitting and vomiting), one third of the infants with severe symptoms have a normal pH probe study!  Moreover, less than 40% of infants with severe esophagitis due to chronic gastrophageal reflux will demonstrate abnormal pH probe studies.

Perhaps the greatest potential value of pH probe analysis is in trying to correlate gastroesophageal reflux with unusual or persistent symptoms such as apnea, stridor, coughing or wheezing, choking, gagging, or unexplained irritability. If these symptoms occur frequently enough, a pH probe analysis can be performed to determine if these symptoms occur at the same time as episodes of acid reflux into the esophagus.

Endoscopy with biopsies

This is the most invasive of all of our tests. With this procedure, a flexible endoscope with lights and lenses is passed down through the infant's mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present. In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). The greatest problem with this test is that most infants with symptoms of gastroesophageal reflux do not develop esophagitis (less than half of infants with severe symptoms of gastroesophageal reflux demontrate esophagitis at endoscopy) and so a normal test does not necessary mean the child does not have reflux. 

As you can see, none of these tests is perfect . . . they all have strengths and weaknesses and they each provide a different type of information.  In most cases, the diagnosis of gastroesophageal reflux can be made clinically based on a careful history and physical examination. In children whose development is delayed or disordered, it is appropriate to consider gastroesophageal reflux when the child suffers from recurrent pneumonia or aspiration, is chronically irritable without any apparent explanation, or does not grow well despite receiving adequate numbers of calories. Diagnostic tests are primarily useful when trying to associate these types of unusual or severe symptoms with gastroesophageal reflux, but offer little information about the ultimate outcome or appropriate treatment strategies.