Gastro-esophageal reflux (GER) in Babies

GER is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Reflux is a normal process that occurs in healthy infants, children, and adults. Most infants have brief episodes, during which they spit up milk or formula through the mouth or nose. 


Uncomplicated reflux:

Gastro-esophageal reflux is common in infants during the first few months of life, with approximately 50 percent of infants between birth and three months having at least one episode of spitting up per day. Infants who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These infants are sometimes referred to as "happy spitters". In this group, spitting up is a natural consequence of the baby's anatomy, because the short esophagus and small stomach allow liquid to escape from the stomach easily. Burping frequently during feeding and limiting activity after feeding may reduce the frequency and amount of spitting up.
Specific testing is not usually necessary for children with uncomplicated reflux. If the symptoms become worse, appear for the first time after six months of age, or do not improve by the time the child is 18 to 24 months of age, the child should be re-evaluated; a consult with a pediatric gastroenterologist may be recommended.

Complicated reflux:

In contrast, a few infants with reflux are irritable, gain weight slowly, develop recurrent pneumonia, or spit up blood. Infants with these signs and symptoms usually require further testing and may require treatment. Although most infants with reflux improve as they grow, some children have symptoms later in childhood.
Gastro-esophageal reflux disease — Reflux becomes gastro-esophageal reflux disease when acid in the reflux causes irritation or injury to the esophagus. The treatments for gastro-esophageal reflux disease are designed to prevent one or more of these elements from occurring. 
Some of the signs or symptoms that may indicate GERD include refusing to eat, frequently crying or arching the neck and back as if in pain, choking while spitting up, forceful or projectile vomiting, frequent coughing, or not gaining weight. These behaviors are not normal and further testing is recommended to determine if GERD (or another condition) is the cause. 


If a child is suspected of having gastro-esophageal reflux disease, the first step in the evaluation is a complete medical history and physical examination. The need for further testing depends upon what is found, and may include one or more of the following:
  • Laboratory testing (blood and/or urine tests)
  • An x-ray study to evaluate how well the infant swallows and to evaluate the anatomy of the stomach
  • A procedure, called upper endoscopy, to view the lining of the esophagus


Infants with uncomplicated reflux do not require treatment, although the following changes may be recommended if the infant is bothered by his or her symptoms. Infants with gastro-esophageal reflux disease are generally treated first with lifestyle changes, including avoidance of overfeeding and tobacco smoke, a milk-free diet, and thickened feeds.
Many infants with symptoms of reflux will improve with conservative measures alone. In one study, over 80 percent of such infants partially or completely improved with conservative measures alone, including thickened feeds, avoidance of tobacco smoke, and trial of a milk-free diet (semi-elemental formula or restriction of milk from mother's diet if breastfed).
Milk-free diet: Studies report that 15 to 40 percent of infants with reflux have a cow's milk protein intolerance, or "dietary protein-induced gastro-enteropathy". Most children are diagnosed with this condition based upon their symptoms and how they respond to changes in diet; laboratory testing is not usually necessary.
The majority of infants with dietary protein gastro-enteropathy are sensitive only to cow's milk protein, although some are also sensitive to soy protein. To eliminate these proteins from an infant's diet, breastfeeding mothers need to eliminate all milk and soy products from their own diet. In rare cases, the mother may need to eliminate other proteins, although this should only be done with the advice of a healthcare provider.
If the infant's reflux symptoms improve after a two to three week trial, it is reasonable to continue the restricted diet until the child is one year old. At this time, many children are able to tolerate milk without difficulty. If symptoms do not improve, the mother may resume her normal diet.
Formula fed infants can be given a hypoallergenic formula that does not contain milk or soy proteins. This is usually continued for one to two weeks to determine if the infant's reflux improves. If symptoms do not improve, the original formula may be restarted. Almost all infants with dietary protein intolerance outgrow the problem by one year of age.
Thickened feeds: Thickening formula or expressed breast milk may help to reduce the frequency of acid reflux and is a reasonable approach to reducing symptoms in a healthy baby who is gaining weight normally. For babies under three months of age, or those with allergies, it is best to consult with the child's healthcare provider before thickening feeds or changing formulas. 
The usual thickening agent is rice cereal; in other countries, rice starch, carob flour, or locust bean gum may be used. To thicken the feed, one ounce (30 ml) of formula or expressed breast milk is usually combined with one tablespoon (15 ml) of rice cereal. The nipple of the bottle may need to be made larger by cross-cutting it, to allow the thickened liquid to pass. Caution should be taken when the hole in the nipple is larger because the child can choke if the formula comes out too fast. For formula-fed infants, premixed "anti-reflux" formulas also are available, which contain rice starch to thicken the formula.
Women who breastfeed are encouraged to continue doing so; an infant should not be switched to formula for the purpose of thickening the feeds. Breastfeeding may reduce the risk of reflux in infants. 
Positioning: Infants may have fewer episodes of acid reflux if they can be kept upright and calm for 20 to 30 minutes after a feed (ie, carried on an adult's shoulder, not placed in an infant seat). Parents should avoid over-feeding and allow the infant to stop feeding as soon as he or she seems to lose interest.
Like all infants, those with acid reflux should be positioned on the back to sleep. There is no benefit of raising the head of the crib or placing the child to sleep in a car seat. Infants should never be placed on the stomach or side to sleep as these increases the risk of sudden infant death syndrome (SIDS).
Reflux medicines: If an infant's symptoms do not improve after a trial of the conservative treatments discussed above, a trial of an acid-suppressing medicine may be recommended. There are a number of medicines available for the treatment of acid reflux in adults. However, the safety and efficacy of these medicines in infants is quite different.
  • Infants with uncomplicated reflux ("happy spitters") do not benefit from medicines that reduce stomach acid or speed emptying of the stomach.
  • Infants with suspected reflux disease may benefit from a brief trial of a medicine that blocks acid production in the stomach is best studied in infants. If the symptoms do not improve significantly within a few weeks, the medicine is usually stopped.
All of these medicines, even antacids, can cause side effects and are not recommended for infants unless you talk to your child's doctor first.

When to seek help?

Infants with acid reflux who also have the following signs or symptoms should be evaluated by a healthcare provider:
  • Bloody stools, severe diarrhea, recurrent vomiting, or vomiting blood
  • Recurrent pneumonia
  • Delayed weight gain
  • The infant has cried for more than two hours
  • Refusing to eat or drink anything for a prolonged period
  • The infant is under three months of age and has forceful vomiting after each feed, but still appears hungry
  • Behavior changes, including lethargy or decreased responsiveness



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