Reflux Infants Support Association (RISA) Inc
PO Box 1598
Fortitude Valley
Queensland 4006
Ph: 07 3229 1090
Website: www.reflux.org.au
ARBN: 124 656 097
ABN: 64 158 190 024
INC9897441
Email: info@reflux.org.au
Checklist: Reflux Symptoms in Older Children (over 2)
Highlight or circle the symptoms relevant to your child and record details and observations in the right hand column. This checklist
does not offer a medical diagnosis, but rather assists parents to record their concerns and provide a framework for a productive
discussion with their medical professionals. Please keep in mind that all children are different and the listed symptoms may not be
indicative of your own child's symptoms. A child with gastro-oesophageal reflux will not necessarily display all of them, and the
number of signs exhibited does not indicate the severity of their ‘reflux'. There are other signs your child may display as well.
NAME:
DATE:
Feeding issues
Feeding Observations
AGE:
- Displaying a fear of food, unwillingness to eat,
extreme fussiness or unusual eating habits
including restricted types of food
- Behavioural issues around mealtimes including
avoidance
- Refusal to feed or only taking small amounts
despite being hungry
- Gag/splutter or have problems swallowing
- Having difficulties with some textures or with
mixed textures
- Comfort feeding e.g. wanting to snack
frequently, unhappy unless they have
something available to eat
- Needs water constantly
- Asks for milk frequently
- Puts hand in mouth/down throat and/or sucking
on fingers/clothes
- Child experiences food getting stuck part way down
(or complaining of the sensation of it)
Sleeping issues
- Difficulty settling at night
- Frequent night waking
- Restless or easily disturbed sleep
- Preferring to be upright/may object to lying
down
- Prefers to sleep on stomach or left hand side
Weight issues
- Inadequate weight gain
- Weight loss
- Excessive weight gain
- Inconsistent weight gain
Other Typical Symptoms
- Irritability, excessive crying or screaming
- Complaining of pain (sore tummy, sore neck)
- Being clingy, extremely sensitive, easily upset,
demanding
- Vomiting, posseting or regurgitation and/or
complaining of “yukky bits in mouth”
- Recurrent hiccups
- Congestion, ‘snuffling’, wheezing or appearing
to have a cold
- Bad or sour smelling breath
- Hoarseness, change in voice
- Gulping, gagging, spluttering or throat clearing
- Frequent red, sore throat (not necessarily with
infection)
© RISA Inc 2012
Sleeping observations
Average number of hours slept in a 24 hour period:
Average number of wakes per night:
Average duration of awakenings:
Notes
Take child’s record book if available
Notes
What has your child said to you?
If verbalising reflux related pain, how often?
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- Recurrent ear, throat, sinus or chest infections
or croup
- Drooling or excessive salivation
- Unexplained behavioural issues
- Asks for Panadol/Dymadon/Paracetamol/
Mylanta
NAME:
DATE:
AGE:
Is there a history of gastro-oesophageal
reflux in your family? Yes/No
Details:
Does your child have a history of reflux
as an infant?
In-home strategies you
have tried
Notes
To minimise reflux:
 Increase time between dinner/drinks and
bed
 Elevating the bed head to sleep
 Smaller meals more often
Diet Modification:

Any dietary modifications you have
tried
Other Concerns
Notes
Describe any potential triggers that may be relevant:
 Bowel motions (e.g. diarrhoea, constipation,
mucous, blood, unusual colour, offensive
odour)
 Skin rashes
 Allergies or intolerances
 Potential triggers for reflux flares e.g. illness,
change of routine, stress, vaccinations,
constipation, being overtired, types of food
Medical therapies/
investigations:
Notes
Other medical issues that
may be relevant:
Medical recommendations
© RISA Inc 2012
Notes
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