Gastroesophageal Reflux (GER)

  • What is Gastroesophageal reflux (GER)?

    Gastroesophageal reflux (GER), also called acid reflux or heartburn, occurs when stomach contents (acidic stomach juices, foods or fluids) return from the stomach into the esophagus (the tube between the mouth and the stomach). Reflux is very common in infants; it is the most common cause of vomiting or “spitting up” during infancy. In most babies, the problem will get better on its own. However, in some cases, reflux may require attention from a clinician.

    Typically, GERD (gastroesophageal reflux disease) happens when there is a problem with the lower esophageal sphincter (LES), the muscle that opens to let food enter into the stomach and then closes to keep it there. If this muscle relaxes too often or for too long, stomach contents flow back up into the esophagus, causing vomiting or discomfort (“heartburn”).

    Infants with GER can have varied symptoms but common symptoms include:

    • frequent vomiting or “spitting up
    • refusal to eat
    • discomfort and/or fussiness during or after feedings
    • problems sleeping
    • a lot of crying
    • hiccups
    • gagging or choking
    • breathing problems, such as wheezing or coughing fits, at night

    Some infants with GER may have stomach contents move up the esophagus and spill over into the windpipe. This can cause discomfort and lead to problems such as asthma, pneumonia or trouble breathing.

    How Boston Children's approaches gastroesophageal reflux (GER):

    Initially, you will meet with a specialist from Boston Children's Hospital's Division of Gastroenterology, Hepatology and Nutrition  who may recommend trying different ways of positioning and feeding your infant. Some infants may need medicine. If your infant has frequent “spit ups” but appears comfortable and is growing well, no treatment may be needed.

    A few ways to avoid or reduce GER for a baby include:

    • If bottle feeding, provide smaller, more frequent feeds. Over-feeding (giving more formula/breast milk than the stomach can hold) can cause an increase in reflux. (Your provider can help you figure out the right daily amount of formula your child needs.) Hold your baby semi-upright during feedings (not flat). Keep the bottle nipple filled with formula/milk, so your child doesn’t swallow too much air.
    • Do not prop your infant’s bottle, as it may cause your baby to choke or take formula into their lungs.
    • Do not add cereal or other thickeners into the bottle unless your provider tells you to.
    • Burp your baby many times during feedings.
    • After feedings, hold your child upright for at least 30 minutes. Try to keep your baby quiet and relaxed after feedings.
    • For sleep, you may place rolled towels under the mattress to raise the head of the crib 30°. Do not use pillows or other soft sleep positioners in the crib.

    Your physician also may give advice about diet and lifestyle changes that can help manage symptoms, such as:

    • offering your child smaller portions at mealtimes and encouraging your child not to overeat
    • serving dinner at least two hours before bedtime

    For more information on GER or to speak with a member of Boston Children's Division of Gastroenterology, Hepatology and Nutrition, please call 617-355-6058.

    Division of Gastroenterology, Hepatology and Nutrition





    Boston Children's Hospital
    300 Longwood Avenue
    Boston, MA 02115


    Click here for information about our other locations throughout the Boston area.


  • What causes GER?

    Gastroesophageal reflux is often the result of conditions that affect the lower esophageal sphincter (LES). The LES, a muscle located at the bottom of the esophagus, opens to let food into the stomach and closes to keep food in the stomach. When this muscle relaxes too often or for too long, acid refluxes back into the esophagus, causing nausea, vomiting, or heartburn.

    As infants digest their feedings, the LES may open and allows the stomach contents to go back up into the esophagus. Sometimes, the stomach contents go all the way up the esophagus and the baby vomits. Other times, the stomach contents only go part of the way up the esophagus, causing heartburn, breathing problems, or, possibly, no symptoms at all.

    Why is GER a concern?

    Most babies with GER have no symptoms other than frequently spitting up. As long as these children are growing well and not developing other problems associated with GER, such as breathing difficulties, the condition needs no treatment and will resolve on its own with time.

    Some babies who have GER may not vomit, but may still have stomach contents move up the esophagus and spill over into the windpipe (the trachea). This can cause wheezing, pneumonia, and in very rare cases, a possibly life-threatening event.

    Babies with GER who vomit frequently may not gain weight and grow normally. Inflammation (esophagitis) or ulcers (sores) can form in the esophagus due to contact with stomach acid. These ulcers can become painful and also may bleed, leading to anemia (too few red blood cells in the bloodstream). Esophageal narrowing (stricture) and Barrett's esophagus (abnormal cells in the esophageal lining) are long-term complications from inflammation that typically occur in adults.

    What are the symptoms of GER?

    The following are other common symptoms of GER. However, each baby may experience symptoms differently. Symptoms may include:

        •    Belching
        •    Refusal to eat
        •    Stomach ache
        •    Fussiness around mealtimes
        •    Hiccups
        •    Gagging
        •    Choking
        •    Frequent cough
        •    Coughing fits at night
        •    Wheezing
        •    Frequent ear infections
        •    Rattling in the chest

    The symptoms of GER may resemble other conditions or medical problems. Always consult your baby's doctor for a diagnosis.

  • How is GER diagnosed? 

    In addition to a complete medical history and physical examination, diagnostic procedures that may be performed to help evaluate gastroesophageal reflux include:

        •    Chest X-ray. A diagnostic test to look for evidence of aspiration--a condition in which stomach contents spill into the lungs leading to breathing problems and lung infections.

        •    Upper GI (gastrointestinal) series. A diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium, a metallic, liquid used to coat the inside of organs so that they will show up on an X-ray, is swallowed. X-rays are then taken to evaluate the digestive organs.

        •    Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing.

        •    pH testing. A measurement of the level of acidity in the esophagus.

        •    Gastric emptying studies. A test designed to determine whether or not the stomach contents empty into the small intestine properly. Delayed gastric emptying can contribute to GERD, allowing stomach contents to back up into the esophagus.

  • What is the treatment for GER? 

    Specific treatment for gastroesophageal reflux will be determined by your baby's doctor based on:

        •    Your baby's gestational age, overall health, and medical history

        •    The extent of the disease

        •    Your baby's tolerance for specific medications, procedures, or therapies

        •    The expectations for the course of the disease

        •    Your opinion or preference

    In many cases, GER can be relieved through feeding changes, under the direction of your baby's doctor. Some ways to better manage GER symptoms include the following:

        •    After feedings, hold your baby in an upright position for 30 minutes. Because stomach sleeping has been associated with an increased risk for Sudden Infant Death Syndrome (SIDS), check with your baby's doctor about how to position your baby for sleeping.

        •    If bottle-feeding, keep the nipple filled with milk so your infant does not swallow too much air while eating. Try different nipples to find one that allows your baby's mouth to make a good seal with the nipple during feeding.

        •    Adding rice cereal to feeding may be beneficial for some older babies.

        •    Burp your baby several times during bottle-feeding or breastfeeding. Your baby may reflux more often when burping with a full stomach.

        •    Make sure your baby's diaper is not too tight since this can exacerbate reflux.

    Treatment may include:

        •    Medications. If needed, your baby's doctor may prescribe medications to help with reflux. There are medications that help decrease the amount of acid the stomach makes, which, in turn, will cut down on the heartburn associated with reflux.

        •    Calorie supplements. Some babies with reflux will not be able to gain weight due to frequent vomiting. Your baby's doctor may recommend the following:

    • Adding rice cereal to baby formula
    • Providing your infant with more calories by adding a prescribed supplement to formula or breast milk to make the milk higher in calories than normal
    • Change formula to milk-free or soy-free formula if allergy suspected

        •    Tube feedings. Some babies with reflux have other conditions that make them tired, such as congenital heart disease or prematurity. In addition to having reflux, these babies may not be able to drink very much without becoming sleepy. Other babies are not able to tolerate a normal amount of formula in the stomach without vomiting, and would do better if a small amount of milk was given continuously. In both of these cases, tube feedings may be recommended. Formula or breast milk is given through a tube that is placed in the nose, guided through the esophagus, and into the stomach (nasogastric tube). Nasogastric tube feedings can be given in addition to, or instead of, what a baby takes from a bottle. Nasoduodenal tubes can also be used to bypass stomach.

    Many babies with GER will "outgrow it" by the time they are about a year old, as the lower esophageal sphincter becomes stronger. For others, medications, lifestyle, and dietary changes can minimize reflux, vomiting, and heartburn. Surgery to reinforce the lower esophageal sphincter and mechanically discourage reflux may be required in severe cases.

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