In Pediatric patients, Gastro-oesophageal reflux (GER) and Gastro-oesophageal reflux disease (GERD) are common and constitute disorders with a large workload for pediatricians. Clinical symptoms and signs are variable and nonspecific, particularly in neonates and infants. Indeed, many symptoms/signs may be secondary to other diagnoses, such as cow's milk allergy, malformation, metabolic, renal, and neurologic disorders. Thus, this may lead to underdiagnosis, overdiagnosis, and unneeded treatment. Therefore, standardizing information regarding clinical information could help define the diagnosis, observe the therapeutic response, and allow the participation of parents and caregivers in the diagnosis-treatment process. For clinical practice, valid and reliable assessment tools can complement clinical assessment to guide decision-making. Parent-reported assessment tools can be used to compare symptoms between populations and longitudinally to measure change over time or in response to interventions. Few non-invasive Questionnaires are available to measure GER/GERD in infants and children. The primary purpose of this Mini review is to describe the main Symptom-Based Questionnaires. 

Keywords: gastroesophageal reflux, reflux, infant questionnaire, I-GERQ-R, symptom index, symptom questionnaire, GIGER

GER, gastro-oesophageal reflux; GERD, gastro-oesophageal reflux disease; I-GERQ, the infant gastroesophageal reflux questionnaire; I-GERQ-R, infant gastroesophageal reflux questionnaire-revised; GSQ-I, GERD symptom questionnaires for infants; GSQ-YC, GERD symptom questionnaires for young children, GIGER, gastrointestinal and gastroesophageal reflux scale

Gastro-oesophageal reflux and Gastro-oesophageal reflux disease in infants and children: an exploration of symptom-based questionnaires

Concerns

Gastro-oesophageal reflux (GER) and Gastro-oesophageal reflux disease (GERD) are regularly seen in Pediatric clinics, particularly among neonates and infants. So, for very prevalent problems, practical solutions must be appropriate.

Indeed, GER and GERD constitute disorders with a large workload for pediatricians. Thus, this may lead to underdiagnosis, overdiagnosis, and unneeded treatment. Therefore, standardizing information regarding clinical information could help define the diagnosis, observe the therapeutic response, and allow the participation of parents and caregivers in the diagnosis-treatment process. So, measuring symptoms using Questionnaires could be a better option than empirical therapy.

Definitions

GER is a physiological process in healthy infants and children, defined as the passage of gastric contents into the esophagus that occurs during two particular situations:

1. The transient relaxation of the Lower Esophageal Sphincter, and
2. The abdominal pressure and consequent inadequate adaptation of the sphincter tone. GER worsens after feeding and when the infant is in a recumbent position.^12,18–21

In contrast, in GERD, the gastric contents reflux into the esophagus and or oropharynx with symptoms resulting in complications.^4,22–27

The clinical symptoms/signs

GER presents at 15 to 21 days of life when oral intake increases.^1,2 The regurgitation episodes become less frequent when changing from a supine posture to a more upright posture and introducing a complementary diet with the transition to more solid foods.^4,12,27 Despite these episodes, children with GERD eat well and thrive without other symptoms. They may often be named as "the happy spitters."

The presentation of GERD signs and symptoms is broad and unspecific, differs by age, and broadly may be classified as Esophageal or Nonesophageal symptoms and signs. Esophageal conditions commonly include regurgitation and vomiting. Nevertheless, feeding difficulties and intolerances such as poor appetite, feeding refusal, poor food intake, poor weight gain, gagging, back arching during feedings, irritability, presumably painful swallowing, dysphagia, abdominal or substernal/retrosternal pain, Failure To Thrive may occur.^13,28 

In addition, Nonesophageal symptoms and signs include chronic cough, wheezing, stridor, hoarseness, recurrent otitis media, aspiration, laryngitis, and choking. Also, many behavioral problems (excessive crying, irritability, grimacing), sleep disturbances, opisthotonos, torticollis, and den­tal erosions may be present. Apparent life-threatening events can be present as GERD symptoms.^{4,17,24,27,28} 

Diagnosis

As described, the clinical symptoms and signs of GER and GERD are variable and nonspecific, especially in infants and young children. Indeed, this plethora of symptoms/signs may be secondary to food allergy, renal, and neurologic disorders.^29,30 It is essential to obtain information about the age of onset of symptoms, dietary history, characteristics of regurgitation (time, frequency, intensity, relationship with food), growth, dietary and pharmacological treatments performed, and family history. Subsequently, the alarm signs (Table 1) should be ruled out as a first step in managing infant regurgitation and indicating referral.^12,31 Therefore, the diagnosis is primarily clinical.^{4,10,12,32–34} For most patients, history and physical examination without warning signs are essential for diagnosis and sufficient to initiate treatment.²² However, investigations may be necessary when the diagnosis is not evident or in the face of complications.

Investigation

The instrumental investigation depends on the clinical situation 35, and the main used to distinguish GERD from other disorders are:

1. Upper Gastrointestinal Radiography. The objective is to describe anatomic abnormalities (malrotation, hiatal hernia, intestinal obstruction), esophageal peristalsis, and the level of reflux.^36,37
2. Ultrasound is non-invasive, allows real-time GER detection by imaging the gastroesophageal junction, and detects secondary GER (pyloric stenosis, gastric outlet obstruction).
3. Esophageal pH Monitoring. It is a quantitative measure of esophageal acid exposure. It may correlate with symptoms and select infants and children with respiratory symptoms in whom GER aggravates.
4. The Combined Multiple Intraluminal Impedance and pH Monitoring. This test detects acid, weakly acid, and nonacid reflux episodes.^38–40
5. Endoscopy and Biopsy. Infrequently used to evaluate infants and young children. The histopathological results are not sensitive or specific for diagnosing reflux esophagitis.
6. Nuclear Scintigraphy. Gastric emptying studies do not confirm the diagnosis of GERD.

Symptom-based questionnaires 

Questionnaires are based on symptoms and complement clinical assessment. Also, assist in the final treatment decision. Few Questionnaires are available for the Pediatricians.

Questionnaires

1. The Infant Gastroesophageal Reflux Questionnaire (I-GERQ)^13,14

(Orenstein et al, 1996; Orenstein 1993)

The I-GERQ was planned and validated for diagnosis of GERD in children ages 1–14 months. It may help distinguish GER from GERD infants. However, it is too long (138-item).

2. Infant Gastroesophageal Reflux Questionnaire-Revised I-GERQ (I-GERQ-R)⁴¹

(Kleinman et al. 2006)⁴¹

The Questionnaire was based on the I-GERQ,¹³ with acceptable Internal Consistency, Test-Test Reliability, and Group Validity. It is suitable for determining the severity of symptoms, the relationship between reflux and symptoms, evaluating treatment, and identifying differences between cases and controls.⁴² When assessed by parents/caregivers and the Pediatrician, the scores are associated with severity Table 2 summarises the Questionnaire.

3. GERD Symptom Questionnaires for Infants (GSQ-I) and young children (GSQ-YC)

(Deal et al. (2005)⁴³

The GSQ-I is suitable for infants between 1- 11 months, and the GSQ-YC is for children between 1-4 years old. Both questionnaires are easy to use, differentiate GERD from control infants and young children, and assess response to treatment. Tables 3 and 4 summarise both Questionnaires. 

4. The Infant Gastroesophageal Reflux Questionnaire (I-GERQ) modified by Salvatore et al. (2005)⁴⁴

It is an original Orenstein questionnaire, adding 18 items to cover the broad spectrum of clinical presentations of GERD. The number of total items is 35. Table 5 summarises the Questionnaire. 

5. Gastrointestinal and gastroesophageal Reflux (GIGER) Scale⁴⁵

(Pados et al. 2021)⁴⁵

The Questionnaire was developed with a dual intention: assess gastrointestinal and GER symptoms as a parent report. The tool has good Internal Consistency and Reliability. The total score was higher in infants with a GER diagnosis and was correlated with the I-GERQ-R). Table 6 summarises the Questionnaire. 

Concluding remarks

Diagnostic procedures, such as pH-meter, Esophageal impedance monitoring, and Endoscopy, are invasive, uncomfortable, and not always accessible. Therefore, given the plethora of signs and symptoms that GERD can present, applying a Questionnaire could standardize these different findings into a score that would be used for diagnosis and follow-up. However, the Questionnaire could be easily administered and repeatedly applied at each visit to measure infant symptoms/signs and their changes over time. The GER/GERD Symptom Questionnaires, including primary and tertiary care, must be applied, and the sum of the clinical evaluation and the answers to the Questionnaire would help the Pediatrician make a better treatment decision. In conclusion, Questionnaires are a great support, and the choice of which one to use must be based on the specific interest of the Paediatrician, such as only assisting in the initial diagnosis, the evolution of symptoms, treatment, or clinical research.

To all the caring children, parents, and caretakers who taught us and still teach us so much.

Nilton Carlos Machado and Mary de Assis Carvalho contributed to the conception of the work and drafted the final manuscript. Juliana Tedesco Dias, Maria Paula Gasparini da Silva Lippelt, Gabriela Nascimento Hercos, and Thabata Koester Weber revised the manuscript critically.

None.

The authors declare no conflict of interest.

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