Continuing Medical Education Am J Gastroenterol 2009; 104:1278–1295; doi:10.1038/ajg.2009.129; published online 31 March 2009

A Global, Evidence-Based Consensus on the Definition of Gastroesophageal Reflux Disease in the Pediatric Population

Philip M Sherman MD1, Eric Hassall MD2, Ulysses Fagundes-Neto MD3, Benjamin D Gold MD4, Seiichi Kato MD5, Sibylle Koletzko MD6, Susan Orenstein MD7, Colin Rudolph MD8, Nimish Vakil MD9,10 and Yvan Vandenplas MD11

  1. 1Gastroenterology-Pediatric, Hospital for Sick Children, University of Toronto, Toronto, Canada
  2. 2Division of Gastroenterology, British Columbia Children's Hospital/University of British Columbia, Vancouver, Canada
  3. 3Disciplina de Gastroenterologia, Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
  4. 4Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, USA
  5. 5Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
  6. 6Dr von Haunersches Kinderspital, Ludwig Maximilians University, Munich, Germany
  7. 7University of Pittsburgh School of Medicine, Pittsburgh, USA
  8. 8Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, USA
  9. 9University of Wisconsin School of Medicine and Public Health, Madison, USA
  10. 10Marquette University College of Health Science, Milwaukee, USA
  11. 11Department of Pediatrics, UZ Brussel Kinderen, Vrije Universiteit Brussel, Brussels, Belgium

Correspondence: Philip M. Sherman, MD, Gastroenterology-Pediatric, Hospital for Sick Children, University of Toronto, Room 8409, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8. E-mail:

Received 3 December 2008; Accepted 22 January 2009; Published online 7 April 2009.

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To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.



Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.



There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approx8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.



The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.