Improving paediatric reflux care with objective, non-invasive diagnostics

David Wynne, consultant paediatric ENT surgeon at the Royal Hospital for Children in Glasgow, highlights the challenges of diagnosing and managing reflux in infants and children. Drawing on his clinical experience, he discusses how a non-invasive diagnostic approach could support more accurate, evidence-based care for this complex patient group.

Improving paediatric reflux care with objective, non-invasive diagnostics

Reflux is extremely common in infancy and early childhood, however the timely and accurate diagnosis of extraoesophageal reflux in paediatric patients remains challenging. Adults are able to articulate symptoms, such as regurgitation, persistent sore throat or vocal changes, but these features are often absent – or impossible to describe – in younger children. Vomiting and regurgitation are frequent and usually benign in early life, making it difficult to distinguish physiological reflux from a clinically significant disorder.

In infants, reflux may instead manifest through non-specific signs, such as irritability, feeding difficulties, disturbed sleep or poor weight gain. The severity and presentation of reflux can also evolve as the child develops, for example, with dietary changes or as they transition from spending much of their time lying down to sitting upright for longer periods. For older children, presentations such as a chronic cough, hoarseness or dysphonia can hint at an extraoesophageal component, but these symptoms overlap with many other conditions. This diagnostic uncertainty is particularly problematic in children with underlying airway or swallowing disorders, where reflux can exacerbate airway obstruction, interfere with healing following reconstructive surgery, or prolong respiratory symptoms.

Limitations of current diagnostic approaches for reflux

Current investigations for suspected reflux in paediatrics are highly invasive and often poorly tolerated in adults, let alone in young children. Invasive procedures like endoscopies require a general anaesthetic in children – carrying both clinical and logistical risks – with interpretation open to subjectivity. For example, the reporting of endoscopic signs such as erythema or ‘cobblestoning’ of the larynx can vary depending on the observer, the equipment and the lighting. Other methods, including oesophageal pH or impedance monitoring, involve inserting a nasal catheter for 24 hours, an uncomfortable procedure that is often impractical in younger patients. Even radiological studies can offer limited insight, and have the additional drawback of exposing children to ionising radiation.

With few practical, objective tests available, current management is largely empirical, relying on clinical suspicion and therapeutic trials of medication. This approach, while pragmatic, may lead to both overtreatment and missed diagnoses, highlighting the need for more reliable and child-friendly diagnostic tools. These limitations contribute to prolonged uncertainty for families and an increased reliance on medications such as proton-pump inhibitors, which are not without side effects.

The potential role of non-invasive diagnostics for reflux

There is a clear need for a non-invasive, objective diagnostic test that could transform how reflux is assessed and managed in paediatric care. This would enable the objective confirmation or exclusion of reflux at the point of care, reducing the reliance on subjective visual assessments or empirical treatment plans. It could also offer insights into treatment decisions – including whether to start, adjust or stop medication – and would reassure both the patient and their parents with tangible results that support clinical advice, all while avoiding uncomfortable and invasive procedures. Hospitals and trusts would benefit as well, cutting costs and resources by reducing hospital admissions, radiological studies and follow-up appointments. By integrating non-invasive diagnostics into existing pathways, clinicians could make earlier, evidence-based decisions and focus interventions on those children most likely to benefit.

However, further clinical research and real-world evaluation are needed to determine how non-invasive diagnostic approaches could be best implemented within paediatric pathways, identify the patient groups that would benefit the most, and assess the tests impact on treatment decisions and healthcare resources.

Target patient groups of interest

The need for more accurate and accessible diagnostic tools is particularly evident in several paediatric populations frequently encountered in ENT. These include infants with airway malacia, children undergoing airway reconstruction or with a chronic cough, and adolescents presenting with dysphonia. These cohorts present unique diagnostic and management challenges, and clinicians could really benefit from an objective, non-invasive means of confirming or excluding reflux as a contributing factor.

Infants with airway malacia

Airway malacia describes a spectrum of conditions – such as laryngomalacia, tracheomalacia and bronchomalacia – where the airway cartilage is abnormally soft, causing partial collapse during breathing. These infants often present within the first few months of life with noisy breathing, feeding difficulties or poor weight gain. Reflux is commonly assumed to aggravate airway symptoms but, because these children are too young to express discomfort, diagnosis relies heavily on observation and clinical suspicion. An objective test could identify which infants genuinely require intervention for their reflux, monitor response to therapy and help to distinguish persistent reflux.

Children undergoing airway reconstruction

In complex airway surgery, rib cartilage grafts are used to reconstruct sections of the trachea. Reflux and inflammation can interfere with graft revascularisation, leading to graft failure or the formation of granular tissue and, once grafts are lost, they cannot be easily replaced. Objective assessment of reflux both before and after surgery could guide more tailored anti-reflux management, reduce complications and improve surgical outcomes.

Children with a chronic cough

A chronic cough is a frequent reason for referral to paediatric ENT and respiratory services. Many children are treated empirically for asthma or post-viral cough, despite there being no clear diagnostic evidence. In a subset of cases, silent reflux may be the underlying driver, and a non-invasive diagnostic tool could help differentiate reflux-related cough from other causes.

Adolescents with dysphonia

Reflux-related voice changes are increasingly recognised in older children and teenagers, though they are often mistaken for functional voice disorders or the result of vocal overuse. Adolescents may also be more prone to reflux due to dietary habits, lifestyle changes and hormonal factors associated with puberty. Objective confirmation of reflux in this group may inform more targeted voice therapy, dietary modification and treatment.

Shaping the future of reflux care in paediatric ENT

Non-invasive, point-of-care testing has the potential to fill an important diagnostic gap in paediatric ENT. Objective confirmation of reflux could refine patient selection for treatment, reduce unnecessary medication exposure and, ultimately, improve outcomes for children with airway, respiratory and voice disorders. Continued clinical research and multidisciplinary collaboration will be key to determining how to integrate these approaches into paediatric practice in the future. As a clinician, it is important to look beyond best guesses and find better, gentler ways to diagnose and manage reflux in young patients to ensure that every child receives the care they truly need.

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