Alarm findings suggesting underlying pathology in an infant with reflux

Symptoms	Possible implications	Initial evaluation
GI obstruction
Bilious vomiting	Small intestinal obstruction (eg, atresia, malrotation)	GI contrast study
Consistently forceful vomiting	Pyloric stenosis Intussusception	Abdominal ultrasound Abdominal examination (Dance sign)^*
Constipation	Hirschsprung disease or other obstruction	History of delayed passage of meconium passage Rectal examination (empty rectum, forceful expulsion of stool) If any abnormalities, further evaluation for Hirschsprung disease (may include contrast enema, anorectal manometry, suction biopsy)
Abdominal tenderness, distension	GI obstruction or inflammation	Conventional abdominal radiograph GI contrast study
Other GI disease
GI bleeding: hematemesis, hematochezia^¶ (with or without diarrhea)	Common causes: Anal fissure Food protein-associated proctocolitis Rare causes: Peptic esophagitis (GERD) Infectious colitis Eosinophilic GI disease FPIES Inborn error of immunity	Depends on associated findings; may include: Trial of a milk-free diet Upper endoscopy and/or colonoscopy Stool testing for enteric pathogens (for bloody diarrhea)
Onset of vomiting after 6 months of life^¶	Peptic esophagitis (GERD) Anatomic abnormality	May include: Upper endoscopy GI contrast study Feeding evaluation
Food refusal	Oral aversion Eosinophilic esophagitis Food allergy May also be a nonspecific symptom
Coughing with feeds (especially with liquids more than solids) or recurrent pneumonia	Swallowing dysfunction Anatomic abnormalities that cause aspiration (eg, tracheoesophageal fistula, laryngotracheal cleft)	More likely in infants with other congenital anomalies; evaluation may include: Videofluoroscopic swallow study Direct laryngoscopy and/or bronchoscopy
Systemic or neurologic disease
Hepatosplenomegaly	Inborn error of metabolism Storage disease	Evaluation depends on associated features (eg, neurologic symptoms, hypoglycemia, and/or jaundice)
Bulging fontanelle^Δ	Increased intracranial pressure (eg, due to subdural hemorrhage, meningitis, or tumor)	Head imaging Evaluation for sepsis
Macrocephaly or microcephaly	Congenital CNS anomaly Increased intracranial pressure	Timing and additional evaluation depend on associated signs and symptoms (suspected syndrome, inborn error of metabolism, or congenital infection); evaluation may include: Serial monitoring of head circumference Head MRI
Seizures	CNS abnormality (eg, intracranial hemorrhage, hypoxic-ischemic encephalopathy, stroke, anomaly, or tumor) Infantile spasms Infection Inborn errors of metabolism	Head imaging EEG Additional evaluation depends on age and associated symptoms
Hypotonia or hypertonia	Cerebral palsy Other neurologic disorder	Assessment of developmental milestones Neuroimaging Possible evaluation for congenital infection, inborn error of metabolism, or genetic disorder
Syndromic features	Genetic syndromes, eg, trisomy 21	Depends on features and suspected disorder
Recurrent infections	HIV, inborn error of immunity, or other cause	Depends on history and types/patterns of infections
Nonspecific symptoms
Poor weight gain^¶	Many causes	Differential diagnosis and evaluation depend on the duration and associated symptoms and signs
Fever
Respiratory symptoms (pneumonia, wheezing)^◊
Lethargy

Partial list of disorders that may present with vomiting or reflux in an infant and initial steps for evaluation. Refer to relevant UpToDate topics for further information about differential diagnosis, evaluation, and diagnosis.

CNS: central nervous system; EEG: electroencephalogram; FPIES: food protein-induced enterocolitis; GERD: gastroesophageal reflux disease; GI: gastrointestinal; HIV: human immunodeficiency virus; MRI: magnetic resonance imaging.

* The Dance sign refers to emptiness when palpating the right lower quadrant of the abdomen. It can also refer to the absence of bowel gas in the right lower quadrant on an abdominal radiograph.

¶ GERD may also present with mild manifestations of these symptoms (occult blood in the stool, new-onset vomiting, poor weight gain).

Δ The fontanelle should be assessed with the infant in a sitting position and not crying.

◊ Respiratory symptoms are rarely caused by GERD except in infants with predisposing conditions associated with aspiration, such as neurologic conditions, anatomic abnormalities (eg, tracheoesophageal fistula, laryngotracheal cleft), or esophageal dysmotility.

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Alarm findings suggesting underlying pathology in an infant with reflux