Reflux in Babies

What is reflux in babies?

Reflux (acid reflux) is when food from your baby’s stomach travels back up into their esophagus. This may lead to spitting up and/or vomiting. In most babies, acid reflux isn’t problematic. It happens because your baby’s digestive tract isn’t fully mature yet.

Your baby might spit up a lot — even daily — but have no health issues. Healthcare providers call such babies “happy spitters.” That’s because spitting up may not seem to bother your baby at all. Or, they might cry or fuss a little but otherwise be fine. Acid reflux usually goes away before a baby’s first birthday.

For some babies, reflux is more serious and affects their ability to take in enough nutrients. They usually have other symptoms, like blood in their vomit, poor weight gain or chronic coughing. Healthcare providers call these “troublesome symptoms.” Such symptoms mark the difference between gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD).

Gastroesophageal reflux (GER) vs. gastroesophageal reflux disease (GERD)

GER and GERD both refer to acid reflux in people of all ages, but there are important differences:

• Gastroesophageal reflux (GER). This is an occasional episode of acid reflux that older kids and adults describe as indigestion or heartburn. It’s harmless and not a disease. GER in babies usually goes away within their first year. Meanwhile, simple changes to your feeding routine may help your baby spit up less.
• Gastroesophageal reflux disease (GERD). GERD refers to chronic acid reflux that may affect a person’s quality of life and damage their esophagus. Babies with GERD need closer monitoring and may benefit from treatment like medications.

As a concerned parent, how do you tell the difference? It isn’t easy, especially when your baby can’t yet use words to describe how they’re feeling. If your baby spits up a lot and you’re worried, it’s worth having a conversation with your pediatrician. They’ll consider your baby’s symptoms and medical history to diagnose or rule out GERD and other possible medical conditions.

Spitting up vs. vomiting — what’s the difference?

When thinking about reflux symptoms, it helps to know the difference between spitting up and vomiting. Spitting up means contents from your baby’s stomach easily flow out of their mouth. Your baby might burp, too. Only small amounts come up at a time, and it’s not forced out by strong muscle contractions.

Vomiting, on the other hand, involves muscle contractions. Muscles in your baby’s midsection contract and force out the stomach contents. This usually causes discomfort and crying in your baby, whereas spitting up doesn’t bother them.

GER can involve spitting up and/or occasional vomiting. But if your baby is mostly vomiting rather than spitting up, that could be a sign of GERD or another condition.

How common is reflux in babies?

Reflux in babies is very common. About 50% of infants up to 3 months old show signs of reflux, like spitting up, at least once a day. About 66% of infants show daily signs of reflux by 4 months. But by 7 months, that number drops to 14%, and it’s less than 5% by 10 to 14 months. Most of these babies have GER, which is common in the first year and not a cause for concern. However, some of these babies have GERD.

Researchers don’t know exactly how many babies have GERD. Many GERD symptoms are nonspecific. In other words, the symptoms aren’t specific to GERD but instead could point to many other possible causes or conditions. So, it can be hard to know for sure if a baby has GERD.

Researchers do know that GERD is more likely to affect babies and children who:

• Have a hiatal hernia.
• Have disorders affecting their brain or nervous system.
• Have cystic fibrosis.
• Have epilepsy.
• Are born with conditions affecting their esophagus.
• Have asthma.
• Are born early (premature birth).

What are the symptoms of reflux in babies?

The main symptom of reflux in babies is spitting up and/or vomiting that occurs after feedings. Usually, babies spit up a little and go about business as usual. That’s typical for many babies in their first year. But additional symptoms, like refusing to eat or coughing, could indicate gastroesophageal reflux disease (GERD).

Symptoms of gastroesophageal reflux (GER) in babies

Symptoms of GER include:

• Spitting up and/or vomiting after feedings.
• Feedings that take longer than usual or get interrupted by spitting up (occasionally).

Reflux isn’t the only thing that can cause these symptoms. But it’s one possibility.

Babies with GER have normal weight gain and generally don’t have trouble with feedings. They also seem unaffected by the reflux.

Infant reflux usually begins at 2 to 3 weeks and peaks at 4 to 5 months. It should fully go away at 9 to 12 months. It’s unusual for GER symptoms to start during the first week of a baby’s life or after a baby turns 6 months. In these cases, the symptoms may point to GERD or another condition.

Symptoms of gastroesophageal reflux disease (GERD) in babies

Symptoms of GERD in babies include:

• Spitting up and/or vomiting, which may be forceful.
• Discomfort or irritability, which may involve crying or arching of the back during feedings.
• Refusal to nurse or drink from the bottle.
• Not gaining weight or growing.
• Vomiting blood.
• Difficulty swallowing.
• Cough.
• Wheezing.
• Noisy breathing (stridor).
• Hoarseness.

These symptoms could point to many other possible conditions besides GERD. If you notice any of these symptoms in your baby, call your pediatrician.

What causes reflux in babies?

Reflux happens when the muscular valve that connects your baby’s esophagus and stomach isn’t fully developed or opens when it shouldn’t. This valve is a ring-shaped muscle called the lower esophageal sphincter. It relaxes to let food travel from your baby’s esophagus to their stomach. It then tightens to prevent food from traveling back up. This muscle, like all of your baby’s muscles, is still developing during your baby’s first year. So, it might not stay shut as well as it will later on.

Food and acid in your baby’s stomach can sometimes press on the valve and cause it to open when it shouldn’t. This might happen if your baby is very full or suddenly changes position (for example, from upright to lying down).

What are the complications of reflux in babies?

GER doesn’t cause complications. However, GERD may lead to:

• Delays in normal weight gain and growth.
• Reflux esophagitis.
• Esophageal strictures.
• Barrett’s esophagus.
• Respiratory problems.

How is reflux in babies diagnosed?

Your pediatrician will review your baby’s medical history and do a physical exam. They need to find out if your baby’s reflux is something they’ll outgrow (GER) or a disease that may need treatment (GERD). If they suspect GERD, they’ll look for signs of complications. They must also rule out other conditions that have the same signs and symptoms as acid reflux. Here’s what you can expect.

First, your pediatrician will talk to you about what you notice. They’ll ask questions like:

• At what age did your baby’s symptoms begin?
• Do you breastfeed (chestfeed) or use formula?
• If you use formula, what type? Do you add anything to it?
• How often do you feed your baby and how long is each session?
• How much do you feed your baby?
• What patterns do you notice with spitting up or vomiting? For example, is it always right after a feeding? At night?

They’ll also talk to you about your baby’s medical history and any conditions that run in the family.

Your pediatrician will then examine your baby to check for any signs of medical conditions, including those affecting the brain or lungs. They’ll also measure your baby’s height and weight to see if their growth is on schedule.

All this information helps your pediatrician determine if your baby has GER, GERD or another condition. Your pediatrician may refer you to a pediatric gastroenterologist, who can also evaluate your baby and help reach a diagnosis.

What tests will be done to diagnose this condition?

Most babies don’t need diagnostic testing. Healthcare providers sometimes use testing if:

• They need more information to reach a diagnosis.
• They suspect a baby has another condition besides GERD.
• They want to check for signs of complications.

Possible diagnostic tests in these situations include:

• Upper endoscopy. This test provides an up-close look at your baby’s upper digestive tract through a camera.
• Upper GI series. This test produces moving pictures of your baby’s esophagus, stomach and upper small intestine using X-ray.
• pH impedance study. This test identifies how often contents from your baby’s stomach pass into their esophagus. It also measures the pH level, or acidity, of the contents.

What is the treatment for reflux in babies?

Treatment for your baby’s reflux depends on its severity. Babies with GER don’t need medications. Instead, they may benefit from changes to their feeding routine. Such changes can also help babies with GERD, but these babies sometimes need medications. Rarely, babies with GERD need surgery.

Your baby’s provider will tailor treatment to their needs. Possible treatments include:

• Thickened feedings. This is when you add a substance to breast milk or formula to make it thicker. Research shows this may help reduce visible symptoms of reflux, like spitting up. You should always talk to your pediatrician before trying thickeners. They’ll advise you on whether it’s suitable for your baby and the type of thickener to choose. For example, they may recommend using oatmeal to thicken formula or carob bean thickener for breastmilk.
• Feeding pattern changes. Feeding your baby more often, but with smaller amounts of milk or formula each time, may help with reflux. It’s important to talk to your pediatrician before making such changes to make sure your baby is still getting enough nutrition. If you’re breastfeeding, you should also talk to a lactation consultant or breastfeeding medicine specialist (a physician with specialized training in breastfeeding).
• Removal of cow’s milk protein. Babies who are allergic to cow’s milk protein also spit up and vomit. So, what looks like reflux might actually be an allergy. Your pediatrician may advise eliminating cow’s milk for two weeks to see if symptoms improve. This means if you’re breastfeeding, you’d remove all forms of dairy from your diet. Or, if you’re using formula, you may need to switch to a different type. Your pediatrician will guide you in your unique situation.
• Medications. Healthcare providers only prescribe medications for babies who clearly have GERD, and even then, only in select cases. Medications like proton pump inhibitors (PPIs), can help manage complications of GERD, like inflammation in your baby’s esophagus (esophagitis). But they come with risks and side effects, so providers use them only when necessary and for as short a time as possible.
• Surgery. If other measures aren’t enough to treat GERD or its complications, surgery may be an option. A pediatric gastroenterologist can tell you more about surgical options, including laparoscopic Nissen fundoplication. Providers consider surgery in infants only in select cases.

Can reflux in babies be prevented?

It’s not always possible to prevent reflux. But some simple changes may help your baby spit up less often:

• Burp your baby during and after feedings. Excess gas in your baby’s tummy can cause them to spit up. Burping along the way can help avoid this buildup.
• Keep your baby upright for about 30 minutes after they eat. Don’t go straight to tummy time.
• Talk to your pediatrician about overfeeding and how to avoid it. Your baby’s tummy can only hold so much at one time. Your pediatrician can help you learn ways to pace feedings so your baby gets what they need but isn’t overly full.

What can I expect if my baby has reflux?

Most babies stop spitting up by 9 to 12 months of age. It’s just a phase they go through, and while it can be messy, it’s usually not a concern.

However, GERD can be more challenging to diagnose and treat. Your baby’s provider can tell you more about what you can expect.

When should I call a pediatrician?

Call your pediatrician if:

• You’re concerned or have any questions about your baby’s reflux.
• Your baby has signs or symptoms of GERD.
• Your baby’s symptoms get worse.

It’s also important to be aware of signs and symptoms that could point to other conditions, besides reflux. Call your pediatrician right away if you notice:

• Spitting up or vomiting that starts late (after 6 months).
• Spitting up or vomiting that continues beyond 12 months.
• Persistent, forceful vomiting.
• Vomiting that only occurs at night.
• Vomit that contains blood. In some cases, this may look like coffee grounds.
• Chronic diarrhea.
• Blood in poop (rectal bleeding).
• Swollen belly.
• Weight loss.
• Excessive sleepiness or drowsiness.
• Fever.
• Seizures.

There are many possible causes for these symptoms, including conditions affecting your baby’s digestive system or other organs throughout their body. That’s why it’s important to seek medical care.

When to seek emergency care

Go to the emergency room if your baby’s vomit is green or bright yellow. This means there’s bile in your baby’s vomit, and it may indicate malrotation or another medical emergency.

What questions should I ask my doctor?

It may help to ask your pediatrician:

• What’s causing my baby’s reflux?
• How can I ease their symptoms?
• Does my baby need treatment? If so, what are the benefits and risks?
• What follow-ups does my baby need?
• What symptoms should prompt me to call you?

What is silent reflux in babies?

Silent reflux is when some contents from your baby’s stomach enter their esophagus but don’t come out of their mouth. Instead, they return to your baby’s stomach. In some cases, this is because your baby swallows them. Other times, it’s because the contents don’t make it all the way up to their mouth.

Silent reflux doesn’t mean your baby is silent. Babies with silent reflux may cry, cough or sound hoarse. But since you don’t see your baby spitting up, you might not realize what’s going on. So, the reflux is “silent” in the sense that it’s not obvious to you. Your pediatrician can tell you more about how this might affect your baby.

A note from Cleveland Clinic

No one said these early months would be easy. But nothing can truly prepare you for the concerns and exhaustion you feel when caring for an infant. So, it’s no wonder you worry when you see your baby spitting up, especially if it happens every day. Is this normal? Will my baby get enough nutrition? When will this stop?

It’s important to know that spitting up usually isn’t a medical problem. And it typically doesn’t require medication. But if your baby does have gastroesophageal reflux disease, there are treatments that can help. Take your questions and concerns to your pediatrician. They’ll help you navigate this time, whatever the road may look like.