R-CPD: Pushing the Age of Diagnosis and Treatment…Younger

Introduction

The first known successful treatment of retrograde cricopharyngeus dysfunction (R-CPD) was rendered by the author in 2015. The first peer-reviewed publication codifying both the diagnosis and treatment of the disorder followed in 2019¹. As of June 2026, the Bastian Voice Institute experience has grown to nearly 2,600 treated patients, including children as young as seven years of age.

What Remains to be Done?

In my view, one of the next frontiers of R-CPD is to push the age of diagnosis and treatment younger still—to include six-year-olds, five-year-olds, four-year-olds, and occasionally even younger children. It is conceivable that, in select cases, some profoundly distressed may ultimately qualify for treatment even at that young age.

In our patient population, historical information regarding infancy has been informative.  Among those patients for whom infant history is available, many reportedly burped normally as babies. (When we describe R-CPD as “lifelong” we are referring to the patient’s memory, which of course excludes infancy.) 

However, in an estimated 25% of patients for whom we have information about infancy, parents recall that burping was absent, extraordinarily difficult, or present but inadequate.

Additional historical features they remember are colic, excessive gassiness, frequent, often projectile spitting up, crying, and fussiness.

Within this group is a subset of particularly severe cases. One father, speaking of his teenage daughter, remarked: “Jennifer was our third child. If she had been our first child, she would have been our only child.” While anecdotal, this statement conveys the degree of distress experienced by some families. Parents may become sleep deprived, frustrated, and overwhelmed by a child who cannot be comforted.  

Of course, infant symptoms such as colic, spitting up, or gassiness are common and can be nonspecific. Caution is therefore warranted in attributing such findings to impaired burping. Nonetheless, as our experience with R-CPD continues to expand²³⁴⁵, recurring historical patterns have become increasingly difficult to ignore.

The question naturally arises: could impaired venting of swallowed air through burping contribute to symptoms in at least some infants and young children?

I believe that the answer, for a subset of patients, may be yes.

Consider the composite history represented by Figure 1.

1. A baby feeds normally but  parents observe progressive abdominal distention.
2. The infant becomes uncomfortable and stops feeding.
3. Repeated attempts to elicit a burp are unsuccessful.
4. Then, perhaps twenty minutes from the start of the feeding, forceful vomiting occurs, sometimes projectile in nature.
5. Families may return repeatedly to pediatricians.
6. Formula changes are attempted.
7. Parents may occasionally be made to feel as though they simply do not know how to burp their baby.

Some describe the whole experience as an ordeal for both parent and child.  

In certain cases, feeding becomes a struggle extending into toddlerhood or early childhood. The child begins eating but stops after only a few bites, seemingly due to discomfort or early satiety. Vomiting may diminish with age, but food refusal and feeding difficulty may persist.

Importantly, alternative diagnoses must be carefully considered in young infants. A truly young infant with projectile vomiting may require evaluation for conditions such as hypertrophic pyloric stenosis, often with ultrasound. The point is not to replace differential diagnosis with R-CPD, but rather to include R-CPD within the differential diagnosis when clinical circumstances warrant.

This philosophy mirrors the approach increasingly applied to adults. I have argued repeatedly that R-CPD is, in most instances, a prima facie diagnosis based predominantly upon history, with little or no need for extensive testing. The same principle may ultimately apply to many children, who should be spared what might be termed the “testing regime” whenever possible.

Adult laryngologists willing to acquire the necessary experience can often treat children down to approximately six or seven years of age. This is the case for Bastian Voice Institute clinicians.  In addition, pediatric otolaryngology collaborators may help extend care safely to even younger patients.

Many laryngologists worldwide have embraced the diagnosis of R-CPD in their adult caseload.  The next frontier in R-CPD is not simply treating more adults.  It is instead recognizing the diagnosis in children and helping them earlier—so they do not have to wait years, or even decades, for relief.