Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)

INTRODUCTION — Gastroesophageal reflux (GER) is the medical term for spitting up. It occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Because the stomach naturally produces acid, reflux is sometimes called "acid reflux"; other terms include "regurgitation" and "spilling."

GER is normal and happens frequently in healthy babies. Most babies have brief episodes, usually after feeding, when they spit up milk or formula through the mouth or nose. In most cases, the reflux causes no problems and does not require treatment. Children and adults can also have episodes of reflux, but the food usually does not come out of the mouth and is re-swallowed.

In contrast, in a few babies, GER causes complications. In this case, the condition is known as gastroesophageal reflux disease, or "GERD." Babies with proven GERD may require treatment. Babies who have colic or who are unusually irritable should be evaluated by a health care provider, but, in most cases, they do not have GERD.

GER is different from vomiting, although people often use the terms interchangeably. Vomiting is usually more forceful and is larger in amount, and the baby or child usually seems sick. But, in some cases, it can be hard to tell the difference, especially in babies who spit up forcefully or in larger amounts. (See "Patient education: Nausea and vomiting in infants and children (Beyond the Basics)".)

This article discusses the symptoms, causes, diagnosis, and treatment of babies with GER and GERD. GERD in older children and adolescents is discussed separately. (See "Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)".)

WHY DOES GASTROESOPHAGEAL REFLUX HAPPEN? — When we eat, food moves from the mouth through the esophagus, which is a tube-like structure, then into the stomach (figure 1). The esophagus expands and contracts to propel food to the stomach through a series of wave-like movements called peristalsis.

At the lower end of the esophagus where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). When food enters the top of the esophagus, the LES relaxes to allow food to enter the stomach, then closes to prevent food and acid from flowing backward into the esophagus.

Occasionally, the LES does not stay closed completely or relaxes at the wrong time, allowing the liquids in the stomach to wash back into the esophagus, causing an episode of reflux. This can occur in all age groups but is particularly common in babies. Most of these episodes go unnoticed because the stomach contents stay within the lower esophagus.

When a baby starts to sit up (usually around six months of age), the frequency of reflux often decreases. As the baby grows, the esophagus becomes longer and the angle between the stomach and esophagus becomes more narrow. These changes naturally decrease the frequency of reflux episodes.

WHEN IS REFLUX A PROBLEM? — In most cases, GER is normal, does not need treatment, and improves as the baby gets older.

Normal reflux — GER happens most frequently in babies between three and six months of age. Approximately 50 percent of babies younger than three months of age have at least one episode of spitting up per day. Spitting up disappears in more than 50 percent of babies by 10 months of age, 80 percent by 18 months, and 98 percent by two years of age.

Babies who spit up frequently but who feed well, gain weight normally, and are not unusually irritable are usually considered to have "uncomplicated" reflux. These babies are sometimes referred to as "happy spitters." In this group, spitting up is a natural consequence of the baby's anatomy. You can help reduce the frequency and amount of spitting up by burping your baby occasionally during feeding and trying to keep them calm and upright for 20 to 30 minutes after feeding. (See 'Positioning' below.)

Testing is not usually necessary for babies with uncomplicated reflux. They should be evaluated if the symptoms worsen, appear for the first time after six months of age, or do not improve by the time they are 18 to 24 months of age. Babies also need further evaluation if they are not gaining weight well, are vomiting blood, or have recurrent pneumonia. The evaluation might include consultation with a pediatric gastroenterologist.

Irritability and reflux — Many parents worry that reflux is the cause of their baby's irritability, colic, or difficulty sleeping. However, studies have shown that reflux does not usually cause pain and that medications to reduce stomach acid do not improve irritability [1,2].

Irritability and difficulty sleeping are common problems in babies; these can be part of normal development but, in some cases, are related to an underlying condition. If your baby is irritable and not easily consoled or if they seem to be spitting up much more than normal, they should be evaluated by a health care provider. If there are no other problems, the health care provider might recommend further evaluation or a brief trial of a reflux treatment, such as a cow's milk-free diet and/or thickened feeds. (See 'Treatment' below.)

If your baby often has extreme irritability (when they cannot be comforted), the health care provider might do further evaluations for other causes of irritability, such as GERD or a neurologic problem.

Gastroesophageal reflux disease — In a few babies, reflux causes complications, such as irritation or damage to the esophagus, asthma, or recurrent pneumonia. In this case, the condition is called gastroesophageal reflux disease, or "GERD." This only occurs in a small percentage of babies who spit up frequently.

The amount of reflux required to cause injury to the esophagus is not predictable. In general, damage to the esophagus is more likely to occur when the reflux is very frequent, there is a large amount of reflux, or the esophagus is unable to clear away the acid quickly because of a nerve or muscle problem. Sometimes, GERD develops in babies who are otherwise completely healthy, but it is more likely in those with underlying medical conditions such as Down syndrome or neurologic problems.

Some of the signs or symptoms that might be related to GERD include:

●Refusing to eat

●Frequently crying, arching the back, or twisting the neck to one side, as if in pain

●Choking while spitting up

●Forceful or projectile vomiting

●Spitting up blood

●Frequent coughing

●Not gaining weight normally

Babies with these symptoms should have further testing to determine if GERD (or another condition) is the cause. (See "Patient education: Poor weight gain in infants and children (Beyond the Basics)".)

It can be difficult to know if a baby is in pain. In general, a baby is probably not in pain if they can be consoled by comforting, distraction, or attending to their needs (hunger, sleep, or a diaper change). If you are concerned about your baby's crying, talk with a health care provider about the symptoms and possible solutions. (See "Patient education: Colic (excessive crying) in infants (Beyond the Basics)".)

EVALUATION — If a health care provider evaluates your baby for reflux, they will first review the baby's symptoms and medical history and do a physical examination. If this evaluation suggests that the baby has typical (uncomplicated) reflux, then they might just follow the symptoms during regular check-ups. If the reflux is causing the baby problems or is concerning to you, you can try the general measures and positioning described below.

In some cases, the health care provider might arrange for tests, such as:

●Laboratory testing (blood and/or urine tests)

●An X-ray study to evaluate how well the baby swallows and to evaluate the anatomy of the stomach

●A procedure called upper endoscopy to view and sample (biopsy) the lining of the esophagus

●A neurologic evaluation (for babies with extreme irritability that is not explained)

TREATMENT

General measures for all babies — Babies with uncomplicated reflux ("happy spitters") do not require treatment. However, the following measures are appropriate for all babies and may help to improve the reflux symptoms, in addition to other benefits:

●Avoid exposure to tobacco smoke – If you smoke, or if anyone in your home smokes, this can worsen your baby's reflux and can also cause other health problems. Do not smoke, or allow others to smoke, in your home or car. If you are having trouble quitting, help is available. (See "Patient education: Quitting smoking (Beyond the Basics)".)

●Breastfeed your baby if possible – If you breastfeed your baby, continue breastfeeding if possible. Babies who are breastfed have somewhat less reflux than those who are formula-fed.

●Avoid overfeeding – Try not to feed your baby more than they want. Allow your baby to stop feeding as soon as they seem satisfied or lose interest. If their stomach is too full, they are more likely to spit up. If you are concerned that they are not getting enough milk, you can offer feedings more frequently.

Positioning — It might help to keep your baby upright and calm for 20 to 30 minutes after a feed. The best approach is to carry them on your shoulder. Putting them in a sitting position (eg, in a car seat) does not usually help, because it tends to compress their stomach.

All babies should be positioned on their back to sleep, including those with reflux. They should never be placed on their stomach or side for sleep because this increases the risk of sudden infant death syndrome (SIDS). For some babies, raising the head of the crib might help with reflux, but there is no proven benefit. If you want to try this, only raise it by 2 to 3 inches (approximately 5 to 8 cm) so that your baby does not slide into an unsafe sleeping position. Be sure that you maintain other safe sleep conditions (baby sleeps on their back, on a firm sleep surface, with no pillows or other soft items in the crib). A car seat is not recommended for sleep, except when using the seat for car travel. (See "Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)".)

Trials of dietary changes — If the reflux is still a problem after trying the above measures, you can try a milk-free diet or thickened feeds. In one study, over 80 percent of babies partially or completely improved with avoidance of tobacco smoke, thickened feeds, and a trial of a cow's milk-free diet.

●Milk-free diet – In many babies with problematic reflux who are otherwise healthy, the symptoms may be triggered by cow's milk. The most common cause is cow's milk protein intolerance (CMPI; sometimes called cow's milk allergy, although this is not a true allergy). The symptoms and severity of CMPI vary but typically include some combination of vomiting and/or loose or bloody stools and sometimes eczema. Most babies are diagnosed with CMPI based on their symptoms and how they respond to changes in diet; laboratory testing is not usually necessary. Talk to your baby's health care provider before you try switching to a cow's milk-free diet.

Many babies improve with elimination of cow's milk protein, although soy or other proteins may be triggers for other babies.

The steps for switching to a milk-free diet depend on whether the baby is breastfed or formula-fed:

•Breastfed babies – If you are breastfeeding, try eliminating all cow's milk, beef, and soy products from your own diet for two or three weeks.

-If the symptoms do not improve, you can resume your normal diet. In rare cases, you may need to try eliminating other proteins, but you should only do this with the advice of a health care provider.

-If your baby's reflux symptoms improve during the trial, you should continue the restricted diet for another month or two. Then, you can try reintroducing cow's milk to your diet every few months to see if your baby has outgrown the reflux problem. Some health care providers suggest restarting with milk that has been cooked into foods. Most babies outgrow a cow's milk intolerance by one year of age.

•Formula-fed babies – If you are feeding formula to your baby, you can try changing to an "extensively hydrolyzed" formula that does not contain intact cow's milk or soy proteins (table 1). Try giving the hydrolyzed formula for one to two weeks to see if your baby's reflux improves. If the baby's symptoms do not improve, you can resume feeding the original formula. Or you can try a corn-free formula (eg, the ready-to-feed version of Similac Alimentum), which is helpful for a few babies who are sensitive to corn protein.

Almost all babies with CMPI outgrow the problem by one year of age.

●Thickened feeds – Thickening formula or expressed breast milk (eg, by adding infant cereal) may help to reduce the frequency of acid reflux. This 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, check with the health care provider before thickening feeds or changing formulas. Also, do not use thickened feeds for babies who were born prematurely, as they can cause injury to the intestine. For the rare baby with an inflamed esophagus (esophagitis) due to acid reflux, thickened feeds are not recommended as the only treatment.

In the United States, infant cereal is usually used as the thickening agent; in other countries, rice starch, carob flour, or locust bean gum are sometimes used. Oat infant cereal is a good choice for most babies. Check the ingredients in the infant cereal and avoid types with soy protein, which can be a problem for some babies. To thicken the feed, combine 1 ounce (30 mL) of formula or expressed breast milk with up to 1 tablespoon (15 mL) of infant cereal. Nipples that allow for adjusted flow are available. The thickness of the mixture changes with temperature, so the preparation needs to be checked if heated or refrigerated. For formula-fed babies, premixed "antireflux" or "spit-up" formulas also are available, which contain rice starch to thicken the formula.

If you are breastfeeding, it's best to continue doing so; don't switch to formula for the sole purpose of thickening the feeds. In fact, breastfeeding may reduce the risk of reflux in babies. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)

Medicines — Medications are not recommended for most babies with reflux, because:

●Babies with uncomplicated GER ("happy spitters") do not benefit from medicines that reduce stomach acid.

●Similarly, even for babies who are somewhat irritable, acid-suppressing medicines are unlikely to help. Although these medicines reduce the stomach acidity, the reflux will still happen.

If your baby has concerning symptoms that might be related to acid reflux, such as severe irritability, feeding refusal, or poor weight gain, talk to their health care provider. They might suggest a trial of an acid-suppressing medicine such as omeprazole (brand name: Prilosec) or lansoprazole (brand name: Prevacid). However, if the symptoms do not improve significantly within a few weeks, the medicine usually should be stopped. Antacids (sample brand name: Maalox) and other medicines (eg, famotidine [brand name: Pepcid]) are not as effective as omeprazole and lansoprazole in blocking acid but may help to control symptoms. These medicines can be used occasionally, but not long term, because they can cause side effects in babies.

All of these medicines, even antacids, can cause side effects and are not recommended for babies unless you talk to your child's health care provider.

WILL MY BABY OUTGROW THE REFLUX? — For most babies with reflux, symptoms go away by one year of age and do not recur later in life. For babies with frequent reflux, it's a good idea to monitor their weight gain because some gain weight more slowly than average, while others gain weight faster. Babies with symptoms that last for more than three months are slightly more likely to have reflux later in childhood, but there are no proven health effects.

WHEN TO SEEK HELP — You should contact a health care provider immediately if your baby has any of these symptoms:

●Forceful vomiting after each feed with continued hunger

●Vomiting blood

●Severe diarrhea or bloody stools

●Crying for longer than two hours

●Refusing to eat or drink anything for a prolonged time (for example, for more than six hours during the daytime)

●Behavior changes, including lethargy or decreased responsiveness

You should also talk to the health care provider if you have other concerns about your baby including slow weight gain or unusual irritability.

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Spitting up and GERD in babies (The Basics)
Patient education: Acid reflux and GERD in children and teens (The Basics)
Patient education: Acid reflux and GERD in adults (The Basics)
Patient education: Esophagitis (The Basics)
Patient education: Colic (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)
Patient education: Poor weight gain in infants and children (Beyond the Basics)
Patient education: Colic (excessive crying) in infants (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Gastroesophageal reflux in infants
Gastroesophageal reflux in premature infants
Management of gastroesophageal reflux disease in children and adolescents
Food protein-induced allergic proctocolitis of infancy

Websites — The following organizations also provide reliable health information:

●National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-infants)

●GI Kids (Children's Digestive Health Information for Kids and Parents, available in English and Spanish)

(www.gikids.org/gerd)

●La Leche League International

(www.llli.org/breastfeeding-info)

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

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