Most infants "spit up" milk as part of their daily activities. The action of spitting up milk is known as reflux or gastroesophageal reflux. Reflux is perfectly normal, common in infants, and is rarely serious.
Gastroesophageal reflux (GER) happens when the contents of the stomach wash back into the baby's food pipe. It is defined as reflux without trouble, and usually resolves itself.
Sometimes, a more severe and long-lasting form of gastroesophageal reflux called gastroesophageal reflux disease (GERD) can cause infant reflux.
Contents of this article:
Causes of reflux and GERD in infants
This diagram shows how acid reflux occurs with GERD.
There is a muscle at the lower end of the food pipe called the lower esophageal sphincter. This muscle relaxes to let food into the stomach and contracts to stop food and acid passing back up into the food pipe.
If the muscle does not entirely close, liquid flows back into the food pipe from the stomach. This sequence occurs in all people, but it happens more frequently in infants under the age of 1 year.
GER sometimes goes unnoticed, as the liquid remains in the lower food pipe, or the liquid is regurgitated and vomited.
Reflux, or regurgitation, is common in infants and peaks between 3-4 months of age. Some infants regurgitate at least once a day, while some regurgitate with most feeds.
Regurgitation rates decline as the muscle that controls the flow of food matures, usually by the time an infant is 18 months old.
Although more common in adults, GER can develop into gastroesophageal reflux disease (GERD). This condition may cause more troublesome symptoms and complications. Symptoms include slow weight gain, irritability, unexplained crying, and sleep disturbances. GERD requires treatment to avoid tissue damage to the lining of the food pipe.
Sometimes reflux in infants might be caused by a more serious condition, such as:
- Food intolerance
- Eosinophilic esophagitis, a buildup of a type of white blood cell that inflames or injures the tissue of the esophagus
- Pyloric stenosis, an infant condition that blocks food from flowing into the small intestine
Most risk factors for infant GER are unavoidable and include:
- Temporary relaxation of lower esophageal sphincter after feeding
- Frequent large-volume feedings
- Short food pipe
- Laying down
The following conditions raise the risk of experiencing infant GERD:
- Hiatal hernia
- Neurodevelopmental disorders
- Cystic fibrosis
- Congenital food pipe disorders
- Premature birth
- Parent history of reflux
GER is uncomplicated, and infants with this type of reflux are often called "happy spitters." Infants with GER may sometimes experience frequent vomiting, irritability, prolonged or refused feeding, or back arching.
Refusing to feed, difficulty swallowing, and frequent vomiting may be symptoms of GERD in infants.
Infants with GER have:
- Normal weight gain
- Little difficulty with feedings
- No significant respiratory symptoms
- No neurobehavioral symptoms
However, in contrast, symptoms of GERD in infants include:
- Poor weight gain, weight loss, and failure to thrive
- Feeding refusal or lengthy feedings
- Irritability after eating
- Difficulty swallowing or pain when swallowing
- Frequent vomiting
- Stomach pain, chest pain, and pain in other abdominal areas
- Long-term coughing, wheezing, or hoarseness
- Recurring laryngitis, pneumonia, sinusitis, or inflammation of the middle ear
Infants are unable to say where something hurts, but they may show signs of distress, excessive crying episodes, sleep disturbances, and decreased appetite.
If an infant presents symptoms of GERD, it is important to get advice from a doctor or pediatrician as other, more severe, conditions share some of the symptoms of reflux in infants.
Diagnosis of reflux in infants
Diagnostic tests are not typically used for diagnosing GER or GERD. Diagnostic tests have not been found to be any more reliable than a doctor asking questions and carrying out a physical examination.
If the baby is growing as expected, appears healthy, and seems content, no further testing is required.
Doctors tend to use diagnostic testing if symptoms do not improve, no weight gain is observed, and lung problems are present
Most cases of regurgitation or reflux resolve within the baby's first year and require no treatment.
Reflux is less frequent and less severe in breastfed babies.
For formula-fed infants, reducing the feeding volumes may improve reflux.
The following changes may help improve infant reflux in formula-fed babies:
- Reducing feeding volumes in overfed infants
- Feeding smaller amounts more frequently
- Adding thickening agents (1 teaspoon rice cereal per ounce of formula)
- Trying antiregurgitant formulas
- Trying hypoallergenic formulas for infants allergic to cow's milk protein
- Interrupting feedings to burp the baby regularly
In breastfed babies, removing immunogenic foods, such as cow's milk and eggs, from the mother's diet may improve symptoms.
Laying a baby tummy-side down or left side down while awake and after feedings is linked with fewer episodes of infant reflux. However, while asleep, infants are recommended to sleep on their back to reduce the risk of sudden infant death syndrome.
Keeping infants upright for at least 30 minutes following feeds and elevating crib and diaper-changing tables by 30 degrees may also help prevent symptoms of reflux.
Medications are not recommended for children with uncomplicated reflux. Reflux medications can have complications, such as preventing absorption of iron and calcium in infants and increasing the likelihood of developing particular respiratory and intestinal infections.
If feeding and positional changes do not improve GERD, and the infant still has problems with feeding, sleeping, and growth, a doctor may recommend medications to decrease the amount of acid in the infant's stomach.
Medications that might be prescribed include H2 blockers and proton pump inhibitors (PPIs). These medications ease symptoms of GERD by lowering acid production in the stomach and can help heal the lining of the food pipe. H2 blockers are usually used for short-term or on-demand relief and PPIs are often used for long-term GERD treatment.
Surgical procedures for infant GERD may only be considered in severe cases. If medications are unsuccessful or there are serious complications, surgery may be an option.
Do infants outgrow reflux?
Infants tend to outgrow regurgitation as the lower esophageal sphincter strengthens. Most cases GER will disappear by 18 months of age of earlier.
However, around 2-7 percent of parents of children between the ages of 3-9 years report that their child experiences heartburn, upper abdominal pain, or regurgitation. Around 5-8 percent of teenagers describe the same symptoms.
GERD declines until 12 years of age and then peaks between 16-17 years old. GERD tends to be more common in teenage girls than boys.
GER occurs more often in childhood and GERD occurs more often in adulthood.
Many infants who spit up milk have no complications and "outgrow it" after a year. Most cases of reflux will be uncomplicated GER.
Cases of infant GERD can be relieved through diet and lifestyle changes under the guidance of the child's doctor. Medications are also available to minimize reflux, heartburn, and vomiting.