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.  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.

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.

Causes of GER include 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.  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 age specific pages for suggested volumes.  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.
• 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 our page on How to Decide What to Feed.
• Probiotics have been shown to be beneficial for GER.  Please click here for more information.
• Medications:  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 in Children

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:

• 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.  Click here for more information.
Medications:  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.
• Weight loss that is not planned.
• Failure to gain appropriate weight.
• 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.