Rethinking Gastroesophageal Reflux Disease (GERD) in Infants

Rethinking Gastroesophageal Reflux Disease (GERD) in Infants 150 150 Lauren Dembeck

Novel use of existing technology points to other causes of GERD-like symptoms.

While typically attributed to gastroesophageal reflux disease (GERD), supra-esophageal symptoms, such as cough, back arching and gagging, can be temporally associated with aerophagia, according to a new study by researchers at Nationwide Children’s Hospital.

The findings come from the novel implementation of standard impedance technology combined with a pH electrode to monitor intraluminal flow of air within the esophagus.

“When analyzing a 24-hour tracing from a patient sent to us for symptoms suggestive of reflux, which is often a cause, I was fully prepared to see reflux, but I didn’t see that. Instead, within the two-minute windows that preceded the symptoms, I saw air swallows,” says senior research scientist and principal investigator Fred Woodley, PhD, of Nationwide Children’s Division of Gastroenterology, Hepatology and Nutrition and lead author of the study.

The article, which was published in the Journal of Pediatric Gastroenterology and Nutrition, presents two clinical cases of infants who were referred to Nationwide Children’s for symptoms suggestive of reflux. Standard-of-care, impedance-pH monitoring found little evidence of reflux in these infants. Therefore, following Dr. Woodley’s observation of aerophagia in the monitoring data, the investigators decided to test the hypothesis that pH/multichannel impedance technology could be used to objectively assess the temporal relationship between GERD-like symptoms and esophageal air events, including air swallows, supragastric belches and gastric belches.

The tracing analysis software associated with impedance technology typically autoscans output data to indicate reflux events. Therefore, to test their hypothesis, the team unmarked the tracings and manually analyzed copies of the tracings according to each type of esophageal air event and tested their associations with recorded symptoms.

All three symptoms, coughing, back arching and gagging, were significantly associated with all three esophageal air events:  air swallows, supragastric belches and gastric belches. The authors suspect that esophageal air events are likely to trigger sensory-motor activation of the vagus nerve, resulting in esophageal distention-induced reflexes that mimic GERD symptoms.

“It’s not something that always happens, but it underscores the importance of exploring possible diagnoses other than reflux when some of these symptoms are occurring,” says Dr. Woodley, who is also a clinical assistant professor of pediatrics at the Ohio State University College of Medicine, “Using the impedance technology to mark air swallows, as opposed to reflux events, allows us to do that, and to my knowledge, this was the first time that had ever been done.”

Going forward, the team would like to increase their sample size by continuing to assess infants who are referred for GERD-like symptoms and to test the relationships between pacifier use (and maxillary and lingual ties) and air-swallow occurrence.


Woodley FW, Ciciora SL, Vaz K, Williams K, Di Lorenzo C, Jadcherla S. Novel Use of Impedance Technology Shows that Esophageal Air Events Can Be Temporally Associated with GERD-Like Symptoms. J Pediatr Gastroenterol Nutr. 2019 Sep 23. doi: 10.1097/MPG.0000000000002514. [Epub ahead of print]

About the author

Lauren Dembeck, PhD, is a freelance science and medical writer based in New York City. She completed her BS in biology and BA in foreign languages at West Virginia University. Dr. Dembeck studied the genetic basis of natural variation in complex traits for her doctorate in genetics at North Carolina State University. She then conducted postdoctoral research on the formation and regulation of neuronal circuits at the Okinawa Institute of Science and Technology in Japan.