Fifteen infants with a specific clinical history including awake apnea were evaluated and compared with a control group of infants, using 24-hour studies of esophageal pH, nasal thermistor, impedance pneumography, and heart rate. Thirteen of the 15 children with awake apnea had clearly documented episodes of airway obstruction in associated with gastroesophageal reflux occurring at least twice during the study (mean 3.9 +/- 0.7, range 2 to 9). The control group did not show similar findings. All 15 children with awake apnea had frequent episodes of gastroesophageal reflux. Treatment with home monitoring and reflux precautions was successful in 10 of 15. Five children received therapy with urecholine hydrochloride because of continuing episodes of reflux-associated apnea. Two children subsequently required Nissen fundoplication, primarily for symptoms of severe esophagitis. Our data suggest that in children with awake apnea, the apnea is associated with gastroesophageal reflux. Medical management is usually successful, but fundoplication may be needed in refractory cases.