Esophagitis in distressed infants: poor diagnostic agreement between esophageal pH monitoring and histopathologic findings

OBJECTIVES: Our purpose was to study the relation between gastroesophageal reflux (GER) and esophagitis in infants with persistent distress. STUDY DESIGN: Infants (n = 125, 79 boys; median age, 4.2 months) with persistent distress and clinical symptoms suggestive of GER and esophagitis were retrospectively studied. All had undergone esophageal 24-hour pH monitoring and had upper gastrointestinal biopsy specimens taken. RESULTS: There were 65 (48%) infants with inflammatory changes found in at least one upper gastrointestinal biopsy specimen, of whom 32 (25.6%) had esophagitis; 11 infants with esophagitis also had gastritis or duodenitis. Although infants with frequent regurgitation (n = 65) had significantly more frequent GER episodes per 24 hours (P <.03) and greater fractional reflux time (P <.001) than infants without, this was not associated with histologic esophagitis (P =.33). Of the 32 infants with esophagitis, 9 had abnormal pH monitoring and 23 had nonreflux esophagitis. A separate group of 23 infants had abnormal pH monitoring but no esophagitis. Diagnostic agreement between pH monitoring and esophageal histologic features was poor (kappa = 0.07). CONCLUSION: Esophagitis occurred in one quarter of infants with persistent distress. Abnormal esophageal pH monitoring did not reliably predict esophagitis, suggesting a nonacid peptic cause in some of these infants.     

Esophageal chest pain in children with asthma

Sixteen patients with asthma and chest pain of greater than 2 months duration underwent gastroenterological evaluation utilizing fiber-optic esophagogastroduodenoscopy (EGD), esophageal manometry, and Bernstein testing. Eleven of 16 patients (75%) had endoscopic and histologic evidence of esophagitis. One patient with esophagitis exhibited high-amplitude peristaltic contractions during motility testing. Four of these 11 patients (36%) had a positive Bernstein test. Extended intraesophageal pH monitoring of seven patients with esophagitis revealed significant gastroesophageal reflux (GER) in all of these patients. Chest pain was associated with an episode of GER in three patients (43%). Nine of 11 patients (82%) with esophagitis responded to medical therapy, resulting in resolution of esophageal inflammation and chest pain. One patient required Nissen fundoplication surgery after failure of medical therapy, and one patient who refused surgery progressively developed more severe esophagitis during 9 months of medical therapy. Children with asthma may have chest pain due to gastroesophageal reflux-associated esophagitis that usually responds to medical therapy.     

Esophagitis: optimizing diagnostic yield by biopsy orientation

OBJECTIVES: There is poor correlation between gastroesophageal reflux (GER) symptoms, intraesophageal pH monitoring and endoscopic or histologic appraisal of esophagitis in the pediatric age group. To optimize the diagnosis of childhood esophagitis, histologic evaluation of esophageal pinch and suction biopsies after orientation were compared. METHODS: Thirty consecutive children with GER, age range 6 months to 7 years, were prospectively evaluated with upper gastrointestinal endoscopy and biopsy. Three pinch biopsies and one suction biopsy were examined after different methods of biopsy orientation. The suction biopsy orientated with x 10 magnification represented the standard against which the pinch biopsies were compared. RESULTS: After suction biopsy with tissue orientation using x 10 magnification 90% of biopsies were adequate for histologic appraisal. Ninety-three percent of esophageal pinch biopsies orientated with x 10 magnification were adequate for analysis. After pinch biopsy orientated without magnification 90% of biopsies were suitable for histologic appraisal. Finally, in the pinch biopsy group without formal orientation, only 63% of the biopsies were adequate for histologic analysis and diagnosis of esophagitis. CONCLUSION: Orientation of esophageal pinch biopsies improves histologic appraisal and hence increases the diagnostic yield of esophagitis in children with GER. The tissue fragments can be easily orientated in the endoscopy room before placement in fixative.     

Barrett's esophagus in an infant: a long standing history with final postsurgical regression

Data on the frequency of regression of Barrett's esophagus after medical therapy or antireflux surgery in adult patients are conflicting; these data, with regard to pediatric age, where Barrett's esophagus is considered rare, are scarce and disappointing after antireflux surgery. We report a 4-month-old infant affected by severe reflux esophagitis who developed a junctional-type Barrett's epithelium. Histochemical procedures to detect mucin pattern were also carried out. The regression of Barrett's esophagus was observed 4 months after antireflux surgery whereas medical therapy had been unsuccessful. We suggest that esophageal biopsy should also be performed in the presence of severe esophagitis. Longer follow-up observations of other patients may clarify the role of antireflux surgery when Barrett's esophagus complicates gastroesophageal reflux (GER).     

Upper airway lesions in children after accidental ingestion of caustic substances

Of 33 children admitted within 24 hours after accidental ingestion of a caustic substance, 14 (42.5%) had evidence of upper airway lesions on direct laryngoscopy. Three patients, 10 to 12 months old, needed endotracheal intubation for acute respiratory obstruction; four patients younger than 2 years had severe dyspnea without obstruction; seven patients had mild or no respiratory symptoms. All were discharged without respiratory sequelae, although esophageal stenosis developed in six patients. Nine of 13 patients younger than 2 years, compared to five of 20 patients older than 2 years, had upper airway lesions (P less than 0.01). The frequency of respiratory tract lesions was higher in patients with severe esophagitis. Eleven of 17 patients with severe esophagitis, compared to three of 16 with mild inflammation, had respiratory tract lesions (P less than 0.025). No specific caustic substance predisposed to upper airway lesions.     

Eosinophilic esophagitis

PURPOSE OF REVIEW: Eosinophilic esophagitis (EE) is an isolated, eosinophilic inflammation of the esophagus. In the past, the symptoms of EE were often confused for gastroesophageal reflux (GER). Thus, many physicians unsuccessfully treated patients with EE with medications used for GER. Because the incidence of EE is rising and EE is easily diagnosed by endoscopy with biopsy, it is important for physicians to not only accurately identify patients with EE but also understand the treatment options available. RECENT FINDINGS: While patients with acid reflux may have a few eosinophils, patients with EE have high levels of eosinophils in their esophagus as part of an allergic response to food antigens. The inflammation may cause abdominal pain, nausea, or vomiting. If EE persists for years, it may cause a narrowing of the esophagus that leads to dysphagia. In young children, many of the symptoms of EE mimic those of gastroesophageal reflux. Medications used to treat reflux are not effective against EE. Over the past few years, many new reports and retrospective studies have been written on the subject of EE. The focus of these papers concentrated on the etiology and treatment of EE. SUMMARY: The diagnosis of EE requires a biopsy of the esophagus. Typical allergy tests are not effective for diagnosis of EE because the allergic reaction involved in EE is non-IgE mediated. The most commonly involved foods include milk, eggs, nuts, beef, wheat, fish, shellfish, corn, and soy; however, almost all foods have been implicated. Because allergy tests are often unable to determine the causative foods, complete elimination of all foods is often required. In these cases, patients must be placed on a strict elemental formula for 1 to 3 months to heal the esophagus. Repeat endoscopy with biopsy is often necessary. Several medications have been used including corticosteroids, cromolyn sodium, and leukotriene inhibitors. This review discusses the past year's literature, concentrating on the etiology, diagnosis, and treatment of EE in both children and adults.     

Gastroesophageal reflux among severely retarded children.

Of 136 institutionalized severely retarded children, 20 (15%) had recurrent vomiting. Of these 20, 15 had gastroesophageal reflux diagnosed by x-ray examination, acid reflux text, or both. Esophagitis was noted by endoscopy in ten of 14 patients with GER. Four patients were anemic and six had had one or more episodes of aspiration pneumonia in the 12 months prior to study. Reduced basal lower esophageal sphincter pressure was the most common manometric abnormality noted in the patients with GER. Responses of the LES to bethanechol and swallow were normal, as was the basal pressure of the upper esophageal sphincter. Abnormal propagation of esophageal peristalsis was seen in six patients, all of whom had moderate or severe esophagitis. When compared to the nonvomiting retarded patients, the GER patients had significantly lower mental age and higher incidence of scoliosis. Patients with GER who had basal LES pressure less than 10 mm Hg did not improve with medical management. Recurrent vomiting is a common and serious problem in severely retarded children, the organic cause of which can be demonstrated by the application of appropriate investigative techniques.     

Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis

BACKGROUND: Distressed behavior is common in infants and is often attributed to gastroesophageal reflux (GER) or food protein intolerance. OBJECTIVE: To examine the effect of a hypoallergenic amino acid-based infant formula (AAF) on distressed behavior and GER symptoms in infants who failed to respond to extensively hydrolyzed formula and antireflux medications. STUDY DESIGN: Nineteen distressed infants (9 boys and 10 girls; median age, 5.0 months) with presumed GER underwent gastroscopy (n = 17) and esophageal 24-hour pH monitoring (n = 14). Double-blind placebo-controlled (DBPC) formula challenges of AAF versus previously besttolerated formula were conducted. RESULTS: Nine infants had histologic evidence of esophagitis, and 9 had inflammatory changes in the stomach and/or duodenum. Symptoms remitted in all infants within 2 weeks of the start of feeding with AAF. On DBPC challenge after a median period of 3 months of receiving AAF, 12 infants were intolerant to active formula (distress score, 287 vs 580 min/wk,P =. 01; symptom score, 23.1 vs 36.1, P =.03). Seven infants did not relapse and were considered tolerant (distress score, 470 vs 581, P =.77; symptom score, 29.5 vs 20.2; P =.89). CONCLUSION: Treatment with AAF may reduce distressed behavior and symptoms of GER in infants with food protein intolerance.     

Cimetidine treatment of reflux esophagitis in children: an Italian multicentric study

The effectiveness of cimetidine (30-40 mg/kg/day) was evaluated in 32 children with gastroesophageal reflux disease complicated by esophagitis who entered a random double-blind trial for 12 weeks. Esophagitis was diagnosed in all patients by endoscopy with biopsy. Seventeen patients (age, mean +/- SD: 21.7 +/- 37.65 months) received cimetidine (c-pts), and 15 (age, mean +/- SD: 29.03 +/- 39.73 months) received a placebo (p-pts). All patients received intensive postural therapy. Based on clinical and endoscopic (and histologic) data, 12 c-pts and three p-pts were healed (p less than 0.01), the condition of four c-pts and three p-pts had improved (not statistically significant), and the condition of one c-pt and nine p-pts had worsened (p less than 0.01). Both clinical and esophagitis scores significantly decreased only in the c-pt group, as compared with p-pts. Improvement of esophagitis was seen in all (100%) of c-pts with mild or moderate esophagitis versus 57.14% of p-pts (p less than 0.01) and in 87.5% of c-pts with severe esophagitis as compared with 25% of the p-pt group (p less than 0.01). We conclude that cimetidine is an effective agent for treatment of reflux esophagitis in children. Although gastroesophageal reflux disease in infancy has a naturally self-limited course with conservative care (thickened feedings and posture adjustment), extensive pharmacologic therapy is needed in the presence of esophagitis.     

Acid exposure and reflux esophagitis

Reflux esophagitis is believed to be related to acid exposure, and it is tempting to assume that the extent of mucosal damage should correlate with pH-metering values. In order to test this hypothesis we studied 151 children with gastroesophageal reflux (GER) documented by X-ray manometry, and pH studies fiberendoscopically. Biopsies taken from each child were assigned to one of four grades according to degree of leukolyte infiltration, basal layer thickening, and papillary lengthening. Histologic esophagitis was demonstrated in 59% of cases, but was severe in only 4%. The histologic grade was independent of endoscopic evaluation, which, in addition, upgraded the lesions (73% esophagitis with 19.2% severe grades). It was also independent of the eventual need for surgery. On the other hand, esophagitis grade significantly correlated with percentage of time at pH below 4 (Spearman's r = 0.18, P < 0.05) and number of GER episodes (Spearman's r = 0.28, P < 0.01). Fiberendoscopic-histologic assessment of esophagitis has been useful in our hands as a complement to other diagnostic GER studies, but its value as an isolated procedure is questionable: it is probably very reliable in the relatively rare severe cases, but the clinical picture is so revealing in these cases as to make it unnecessary. In mild and moderate grades, which are much more frequent in children, it was not a suitable method for evaluating the severity of GER and did not assist in the establishment of surgical indications.This investigation has been partially supported by F.I.S.S.S. grants 84/1049 and 87/1605 Offprint requests to: J. A. Tovar     

Effects of domperidone therapy on symptoms and upper gastrointestinal motility in infants with gastroesophageal reflux

We evaluated the effect of domperidone, a novel prokinetic agent, on symptoms and esophageal and gastric motility in 15 infants (six boys), mean age 7.9 months, with moderate to severe gastroesophageal reflux (GER) and upper gastrointestinal motility disturbances. Patients received domperidone orally for 6 weeks and underwent weekly assessment of five GER-associated symptoms, weight change, and side effects. Mean total symptom scores significantly improved after treatment (P less than 0.01). Vomiting, "spitting," and coughing each improved significantly. Postprandial reflux time (defined as esophageal pH less than 4.0) and percent peristaltic esophageal contractions improved significantly (p less than 0.05). Gastric fundic contractions, present in only four infants before treatment, occurred in nine after domperidone administration. Although mean gastric emptying of isotope-labeled formula was not improved, it improved greater than or equal to 10% over baseline in nine patients. Peristaltic amplitude, lower esophageal sphincter pressure, and esophageal acid clearance time were unchanged. Side effects were minimal. We conclude that domperidone is a useful and safe agent for treatment of gastroesophageal reflex in infants because it addresses the motility abnormalities inherent in the pathophysiology of the disorder.     

Barrett's ulcer and Campylobacter-like organisms infection in a child

Barrett's esophagus is a gastrointestinal metaplasia of the esophageal epithelium occurring frequently in adults with long-standing peptic esophagitis. Recent reports of Barrett's esophagus in children with gastroesophageal reflux (GER) showed that also at the pediatric age intestinal metaplasia of the esophagus may occur in association with peptic esophagitis. Recently a close association between Campylobacter-like organisms (CLOs) and gastritis has been found in the stomach of both adults and children with a variety of peptic diseases, but evidence of such infection in specimens of Barrett's epithelium has never been described in children. We report here a child with Barrett's esophagus and GER, treated with H2 blockers, who showed a Barrett's ulcer in association with CLO infection. The addition of amoxicillin to antireflux treatment was accompanied by healing of the ulcer, suggesting that bacterial infection of Barrett's epithelium may have an important role in determining its inflammation and possibly ulceration.     

Recurrent pulmonary disease in children: a complication of gastroesophageal reflux.

To evaluate the role of gastroesophageal reflux (GER) as a possible cause of recurrent pulmonary disease, 30 children, aged 1 to 18 years, were studied prospectively with esophageal function tests. These included esophagram (30 patients), esophageal manometry (29 patients), pH probe (Tuttle) test (29 patients), and esophagoscopy with esophageal biopsy (23 patients). The patients studied had either chronic asthma or two or more documented pneumonias within a one-year period. Nineteen (63%) had GER based on two or more positive tests. Eighteen had positive Tuttle tests; 13 had abnormal manometry studies; nine had esophagitis on biopsy; six had esophagitis on esophagoscopy; and five had reflux on esophagram. Of those with GER, 17 had a history of nocturnal cough and eight vomited during infancy. Children with recurrent pulmonary disease should have esophageal function testing to exclude GER as the cause.     

Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis

OBJECTIVE: Chronic gastrointestinal symptoms and histologic changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux disease (GERD) may be improved by the use of elemental formulas. The aim of our study was to evaluate the efficacy of a dietary trial in neurologically impaired children unresponsive to medical and surgical therapy for GERD. METHODS: Nine children (three boys and six girls; median age, 44 months; range, 13-180 months) affected by cerebral palsy associated with severe mental retardation and with long-standing history of GERD were fed the elemental formula, Neocate, for a minimum of 4 weeks. Before and after the dietary trial, each child underwent endoscopy with esophageal biopsy and a cellobiose/mannitol sugar permeability test. The diagnosis of GERD was based on the microscopic changes of the esophagus. RESULTS: Before the dietary trial, according to conventional histologic criteria, esophagitis was considered moderate in seven children and mild in two. Five of nine patients also had abnormal sugar permeability test results. During and after the dietary trial, seven of nine patients experienced resolution of their long-term symptom complaints. Furthermore, after the dietary trial, both endoscopic ( < 0.01) and histologic ( < 0.05) findings significantly improved. At 6-month follow-up, progressive reintroduction of individual dietary proteins, except for cow's milk protein, did not cause reappearance of the symptoms. CONCLUSIONS: In neurologically impaired children unresponsive to conventional antireflux treatments, a course of a highly restricted diet with an amino acid-based formula may bring an immediate and sustained, endoscopically and histologically proven improvement in long-standing gastrointestinal symptoms and esophagitis.     

Gastroesophageal reflux in children. Clinical profile, course and outcome with active therapy in 126 cases

A clinical profile and the course and outcome with therapy of 126 infants and children with gastroesophageal reflux (GER), diagnosed at a median age of 2.5 months and followed for 1.5 to 3.5 years is presented. Features included repeated regurgitation or rumination (99%), signs suggesting esophageal pain (49%, excessive crying "colic," sleep disturbance, Sutcliffe-Sandifer syndrome, respiratory symptoms 42%), failure to thrive (18%), and minor hematemesis (18%). Feeding problems and maternal distress were common, associated with child abuse in four cases. Therapy was initially conservative (posture, thickening of feeds, antacids, bethanechol), augmented by cimetidine in those with proven esophagitis (n = 34, 0.27%). Most (81%) were symptom-free by 18 months of age (55% by 10 months of age); 17 percent had fundoplication with good results; 2 percent have persisting symptoms beyond 2 years of age (1% failed surgery). No deaths were recorded. Surgery was performed for recurrent apneas/aspiration (6%), refractory esophagitis or stricture (5%), and failed medical management (7%). Esophagitis was a significant determinant to outcome, and the importance of selective early endoscopy is emphasized. GER is a cause of considerable morbidity in infants but, with active therapy, is self-limiting in the majority. Certain distinctive clinical signs indicate those patients who require detailed investigation and to whom more aggressive therapeutic efforts should be directed.     

Simultaneous recording of pH in the distal and proximal esophagus]

A 24 hour esophageal pH recording was performed in 46 infants (age: 10 +/- 12 months). Two probes were placed in the proximal and distal esophageal sites respectively. A significant correlation was shown between the upper and lower part of the esophagus for the numbers of acid (pH fall below 4 for at least 15 s) and weakly acid (fall in pH of more than one unit, irrespective of whether or not the pH fell below 4) gastroesophageal reflux (GER), the reflux index and the number of acid GER longer than 5 min. The number of acid GER and the time spent at pH less than 4 at the proximal esophagus were significantly greated in group 1 (reflux index greater than 5% in the distal esophagus, n = 10), than in group 2 (reflux index less than 5% in the distal esophagus, n = 36). The proportion of distal acid and weakly acid reflux reaching the upper esophagus presented with marked variation coefficients. These findings indicate that data obtained in the distal esophagus are poorly predictive of the results in the proximal esophagus, even if infants present high reflux index at the lower esophagus. Weakly acid GER reached the upper esophagus more frequently than acid GER.     

Omeprazole maintenance therapy for gastroesophageal reflux disease after failure of fundoplication

BACKGROUND: Recurrence of gastroesophageal reflux (GER) in children after failed fundoplication poses a therapeutic challenge. The authors report the experience with long-term omeprazole for children with severe GER after failed fundoplication. METHODS: The authors reviewed the charts of all children who were treated with omeprazole for GER subsequent to failed fundoplication from 1990 to 1999. All underwent endoscopic and clinical assessment of the treatment at baseline, at 3-5 months, at 6-9 months, and annually. RESULTS: Eighteen children presented with GER, after a total of 27 fundoplications. Ten had corrected esophageal atresia, 6 had neurologica impairment, and 2 had hiatal hernia. The mean age of presentation of children with recurrence of GER was 7.8 years, and symptoms of GER occurred 4.9 years (range, 0.6-13) after last fundoplication. Fifteen patients had a mean follow-up of 4.4 years for omeprazole. Ten patients had grade III/IV esophagitis and 5 had grade II esophagitis at presentation after fundoplication. Marked improvement was noted in symptoms of GER and severity of esophagitis while taking omeprazole. Remission of esophagitis was maintained while the patient was taking omeprazole and none had further surgery. There was no recurrence of peptic strictures in eight of nine children on omeprazole, after initial esophageal dilatations. Except for benign gastric polyps in three patients, no clinical adverse effects were observed. CONCLUSIONS: Omeprazole is an effective long-term drug for gastroesophageal reflux disease after failed fundoplication in children. Omeprazole was well-tolerated by all children and should be tried before subsequent surgical intervention.     

Clinical and endoscopic predictors of histological oesophagitis in infants

Objective: To define the earliest age at which histological changes can be used to diagnose oesophagitis and to determine the relationships between clinical, endoscopic and histological features of oesophagitis in infants.
Methodology: The case records and biopsies of 113 infants aged 2–18 months with clinically significant gastro-oesophageal reflux (GOR), undergoing oesophagoscopy between 1978 and 1994 were retrospectively reviewed. The biopsies were independently evaluated and graded by two pathologists.
Results: Forty-five cases (40%) had histological oesophagitis but only 16 (14%) had abnormal endoscopic findings (excluding erythema). Endoscopy was found to be highly specific (93%) for histological oesophagitis but lacked sensitivity (25%). Irritability was inversely related to the presence of endoscopic abnormalities, and there was poor correlation between symptoms and histological changes with only haematemesis showing a statistically significant association with histological abnormalities ( P = 0.033). Intraepithelial lymphocytes were the earliest of the histological features noted and were present before 4 months of age. The numbers of intraepithelial eosinophils and lymphocytes and the presence of papillary elongation all increased with age.
Conclusions: The presence of oesophagitis is difficult to predict on the basis of symptoms. The presence of intraepithelial lymphocytes is the earliest histological change to be seen in infants with GOR, and can develop before 4 months of age. Oesophagoscopy without biopsy is unreliable in the diagnosis of oesophagitis in infants.     

Correlation between gastric acid secretion and severity of acid reflux in children

The purpose of our study was to systematically evaluate gastric acid output in children with long-lasting gastro-esophageal reflux (GER) in order to assess its mechanism and the need for anti-acid treatment. The investigation was carried out in 20 males and 10 females, aged 7.5 +/- 3.8 years, with prolonged (>15 months) clinical manifestations of GER. All underwent routine ambulatory 24-h esophageal pH-monitoring and measurement of gastric acid secretion including gastric basal (BAO) (micromol/kg/h), maximal (MAO) and peak acid outputs (PAO) after pentagastrin (6 microg/kg sec) stimulation. Children with heartburn or abdominal pain underwent upper fiber-endoscopy. In group A (moderate GER, n=12), patients had a normal reflux index (pH<4 below 5.2% of total recording time) despite abnormal Euler and Byrne scoring (median 57, 95% confidence interval 53.5-73.4). In group B (severe GER, n=18, among whom 5 were with grade III esophagitis), reflux index was >5.2%. When considering all children, esophageal pH (%) was significantly correlated with MAO and PAO, r=0.33, p=0.05 and r=0.37, p=0.04, respectively. Children of group B exhibited significantly higher BAO (75, 53.96-137.81), MAO (468, 394.1-671.3) and PAO (617, 518.8-782.3) than those of group A, BAO (27, 10.8-38.5), MAO (266, 243.2-348.2) and PAO (387, 322.5-452.7), p<0.05). The five children of group B with severe esophagitis exhibited significantly higher BAO, MAO and PAO than the other 13 children from the same group and those of group A, p<0.05. Children with long-lasting and severe GER hyper-secrete gastric acid. Individual variations in gastric acid secretion probably account for variations in gastric acid inhibitor requirements. Anti-secretory treatment is justified in children with long-lasting GER and high pH-metric reflux index.     

Gastroesophageal reflux in the older child: presentation, response to treatment and long-term follow-up

Much attention has been focused on the natural history of gastroesophageal reflux (GER) in neurologically normal infants which generally resolves by two years of age. In contrast, little is known of the outcome of GER diagnosed in normal older children. The charts of 32 children (21 males) without neurologic or esophageal anatomic abnormalities, age 3.5 to 16 years (mean = 9.8) at the time of diagnosis, were reviewed. Diagnosis was based on suggestive presenting symptoms and evaluation of prolonged intraesophageal pH monitoring. Esophagitis was diagnosed by histologic criteria in 16 of the 32 patients. Medical treatment consisted of prokinetic agents (metoclopramide, bethanechol) and H2-receptor antagonists. After a one to eight year follow-up period (mean +/- SD - 3.4 +/- 2.1), the symptoms in 13 children had resolved or were sufficiently improved to discontinue medication. In 13 patients, symptoms were improved but medication was required for adequate control. Four children were symptomatic without improvement in spite of medical therapy and two others required fundoplication for continued severe symptoms and refractory esophagitis. In summary, less than 50% of otherwise normal older children with GER undergo spontaneous resolution of marked improvement in symptoms and the remainder require continued long-term medical and/or surgical management.