• Gastroesophageal reflux (GER) is present in most infants and will typically resolve as the child grows. • Symptoms include discomfort while eating and emesis and can progress to pulmonary symptoms such as cough or choking with aspiration. • Concerning side effects include failure to thrive, chronic respiratory disease, esophagitis, stricture, or acute life-threatening events (ALTE). • At-risk patients include those with development abnormalities—tracheoesophageal atresia, abdominal wall or diaphragmatic defects, and neurological impairments. • Surgical treatment of GERD has large variations and there is little literature to support surgery as the best first treatment. • Medical management should include trial of antiacid with monitoring of symptoms during the treatment. • In failure of medical management, imaging with UGI should be performed to determine if there are any anatomical abnormalities. • Anatomically anomalies such as hiatal hernia would need surgical treatment with fundoplication as part of their procedure. • Documentation of GERD with an impedance probe can best show correlation between the patient’s symptoms and reflux. This is not always available, and a pH probe can also be used. • Long-term side effects of GER result in metaplasia with Barrett’s esophagus. • In older pediatric patients, you must assess their nutritional status prior to performing surgery. • Complications include continued reflux, or wrap slipping/migrating into the thoracic cavity. • Differential: eosinophilic esophagitis and hiatal hernia. • For NICU babies, retching and arching will commonly be described by the nurse.