Illnesses & Symptoms
What is Gastroesophageal Reflux?
Gastroesophageal Reflux (GER) is when food or liquids come back up from the stomach into the esophagus and maybe into (or out of) the mouth and/or the nose. This happens when the muscle (sphincter) at the top of the stomach is loose and allows food/fluids to go backwards through the intestinal system. It can happen at any age.
What are the Symptoms?
In infants symptoms can include irritability, arching of the back, poor feeding, poor sleep, refusal to lay down, wheezing, frequent ear infections, and spitting up (but some might swallow before you see the spit up) in infants.
In older children and adults symptoms of chest pain, heart burn, refusal to eat, wheezing, chronic cough, chronic hoarse voice, weight loss, and erosion of the enamel on molars.
Not all symptoms are needed to diagnose GER. The severity helps to determine what treatments, if any, are needed.
What are the Causes?
Nearly half of all babies spit up part of their feedings. Most spit up immediately after a feed, but some spit up hours later, just before the next feed. It seems to worsen about 4 months of age and usually goes away by a year of age. This is considered a normal process and is common.
Causes of GER include overfeeding, immaturity of the muscle between the esophagus and stomach, allergies to foods (especially cow's milk products), or less commonly an abnormal location of the stomach — a hiatial hernia is when the stomach can enter the chest through a large hole in the diaphragm.
Severe vomiting that projects several feet in a young infant and progressively worsens to the point of dehydration might indicate a different condition called pyloric stenosis. If you young infant (usually 3 weeks to 3 months) has worsening of spitting up and a decrease of wet diapers, you must have that infant evaluated.
Diagnosis often is based on a careful history and exam including looking at the growth chart over time. If the diagnosis is not clear or if the response to treatment is not ideal, the following testing might be done:
- Upper GI series: Barium is swallowed and an x-ray is taken to see how the stomach empties. Reflux may or may not be seen during the study, even if it occurs at other times.
- Endoscopy: A gastroesophageal specialist can use a tube with a camera in it to look at the esophagus and stomach to see signs of irritation or inflammation. Biopsies can be taken if needed for diagnosis. This test is done under sedation.
- Esophageal pH probe: A small tube is put into the stomach through the nose. This tube has sensors that can measure acid. It is left in, usually 24 hours, to measure how often acid reaches various sensors. This test requires hospitalization.
Gastroesophageal reflux in infants
Gastroesophageal reflux (GER) can begin early in life, and most babies will spit up at least sometimes. Small mouthfulls of spit up in a healthy, growing, happy infant is normal. Even larger volumes of spit up in a healthy, growing, happy infant can be acceptable. GER usually resolves between 6 and 12 months of age, as solid foods are introduced and babies are upright more.
Treatment in infants can include the following:
Decreasing the volume of each feeding
This might require increasing the number of times your baby feeds to get in adquate calories throughout the day. Please visit our feeding section for suggested volumes by age range. Overfeeding distends the stomach and increases GER. Breastfeeding infants are more difficult to estimate volumes, and we often monitor their weights very closely to be sure volumes are appropriate. Do NOT simply limit the amount of time your baby spends on each breast. This can cause the baby to get the low-fat foremilk without any of the needed high fat hindmilk. Work with your physician for feeding suggestions if you think your breastfed infant is getting too much.
Hold baby in an upright position while feeding
Burp your baby often during feeds to decrease the stomach distension caused by excess air in the stomach.
Elevate the head of baby's bed 30-45 degrees
If your mattress has different elevations this can be done by putting one side higher. You can also put rolled blankets under the mattress. It is never recommended to put pillows or other soft objects under your baby's head because of the risk of suffocation. Car seat positioning has been shown to worsen the reflux (likely due to the legs pressing up on the abdomen).
Breastmilk is usually best tolerated by your baby and is recommended
If unable to breastfeed, partially hydrolyzed formulas are recommended. For more information on why we recommend this, see How to Choose What to Feed.
Thickening the bottled breast milk or formula has been shown to decrease the regurgitation seen in infants with reflux. Parents who use rice cereal to thicken (1 TBSP powder cereal to 1 ounce milk/formula) increase the calories from about 20 cal/oz to 34 cal/oz. This can cause babies to get too many calories. There are formulas made to thicken in the stomach (such as Enfamil AR) that do not give the added calories. These cannot be given with an antacid of any kind because they need the acid to thicken the formula.
Probiotics have been shown to be beneficial for GER
For more information on probiotics, visit US Probiotics. For a searchable database on various brands of probiotics, see the Clinical Guide to Probiotic Products
Antacids can be used when babies fail to gain weight, are extremely irritable, or have secondary complications of the GER (such as ear infections or wheezing).
- Antacids that neutralize the acid in the stomach include sodium bicarbonate (found in Gripe Water for infants), and ranitidine or nizatidine (only available by prescription for infants). These neutralize the acid in the stomach and are taken 2- 3 times per day.
- Proton pump inhibitors keep the stomach from making acid. They are available by prescription only and often require a prior authorization by your insurance company.
- Talk with doctor if you think your infant needs one of these medications.
Gastroesophageal reflux (GER) in children occurs when the stomach contents enter the esophagus. An occasional "wet burp" can be normal, but when it is associated with the symptoms listed above, GER deserves attention.
Treatment of reflux can be started at home
Gastroesophageal Reflux in Children
- If a child is overweight, working with your physician for appropriate weight loss can help decrease reflux.
- Eating small meals decreases the stretch of the stomach, which leads to less reflux.
- Avoid certain foods: Caffeine, chocolate, carbonated beverages, foods high in fat, foods high in acid (citrus, tomatoes, pickles), and spicy foods.
- Avoid eating before nap or bedtime and right before heavy exercise.
- Elevate the head of the bed 30 degrees.
- Avoid cigarette smoke exposure.
- Probiotics have been shown to be beneficial in treatment and prevention of GER. Visit US Probiotics for more information.
- Antacids can be used when above treatments fail or if symptoms require more immediate action.
- Calcium carbonate is available over the counter in the form of Maalox, Tums, or Pepcid. They can neutralize acid and work well for occasional temporary relief of heartburn. It is acceptable to try these at home before visiting the physician if you want to see if they work, but if your child needs to use them regularly, please make an appointment for your child to be evaluated.
- Antacids that neutralize the acid in the stomach include ranitidine or nizatidine (only available by prescription for liquid formulations, but over the counter forms of ranitidine, cimetidine, and famotidine are available). These neutralize the acid in the stomach and are taken 2-3 times per day. Please make an appointment to discuss use of these medications in your child before beginning treatment.
- Proton pump inhibitors (omeprazole and lansoprazole) keep the stomach from making acid. They are available by prescription and one type is available over the counter. The prescription often requires a prior authorization by your insurance company.
- Talk with doctor if you think your child needs one of these medications except occasional use of calcium carbonate or ranitidine
When to see your doctor:
- If above home care does not help after 2 weeks or if you desire starting medication for your child.
- Signs of dehydration: no tears, dry lips or mouth, fewer wet diapers.
- Weight loss that is not planned.
- Failure to gain appropriate weight.
- Projectile vomiting: many people describe all vomiting as projectile, but true projectile vomiting can land several feet away from the child.
- Uncontrollable pain.
- Vomiting not due to viral illness (which usually lasts less than 1-2 weeks and is followed by diarrhea).
- Swallowing problems or complaints that food is "stuck."
- Breathing problems: Chronic cough, wheezing or asthma that isn't controlled well.
- Hoarse voice lasting more than 2 weeks.
- Dental problems: Dentists often notice poor enamel due to acid washing the molars during sleep. This can lead to cavities if untreated. Any child with GER should follow with the dentist closely.