Gastroesophageal Reflux 1

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia (difficulty swallowing), abdominal or substernal pain, esophagitis and respiratory disorders. During infancy GER is common and is most often manifest as vomiting. Recurrent vomiting occurs in 50 oercent of infants in the first three months of life, in 67 percent of four-month-old infants, and in 5 percent of 10- to 12-month-old infants. Vomiting resolves spontaneously in nearly all of these infants. Parents do not usually perceive vomiting as a problem when it occurs no more often than once daily, but they are more likely to be concerned when vomiting is more frequent, the volume of vomitus is large, or when the infant cries frequently with vomiting.

In unusual cases,infants develop GERD with symptoms including anorexia, dysphagia (difficulty swallowing), odynophagia (painful swallowing), arching of the back during feedings, irritability, hematemesis, anemia or failure to thrive. GER is one of the causes of apparent life-threatening events (ALTE) in infants and has been associated with chronic respiratory disorders including reactive airways disease, recurrent stridor (wheezing), chronic cough and recurrent pneumonia in infants.

  1. The Infant with Recurrent Vomiting:
    In most infants, symptoms of GER do not decrease when there is a change from one milk formula to another. However, a subset of infants with vomiting has cow's milk protein allergy. In these infants, elimination of cow's milk protein from the diet resulted in decreased vomiting within 24 hours. Two successive, blind challenges corroborated the diagnosis of cow's milk protein allergy-induced vomiting in infants. There is, therefore, evidence to support a one- to two-week trial of a hypoallergenic formula in formula-fed infants with vomiting.
  2. Infants with Recurrent Vomiting Unresponsive to Hypoallergenic Formula:
    Milk-thickening agents do not improve reflux index scores but do decrease the number of episodes of vomiting. Use of thickened formulas compared with standard formula significantly increased the percentage of infants with no regurgitation, slightly reduced the number of episodes of regurgitation and vomiting per day (assessed jointly or separately), and increased weight gain per day; it had no effect on the reflux index, number of acid gastroesophageal reflux episodes per hour, or number of reflux episodes lasting >5 minutes but significantly reduced the duration of the longest reflux episode of pH <4. No definitive data showed that one particular thickening agent is more effective than another.2The primary care provider should complete a medical documentation form for WIC and include instructions for mixing cereal with formula for the purpose of thickening.3Some parents may have difficulty adding the appropriate amount of cereal and mixing the thickened formula. In these special cases a pre-prepared ;starch added formula may be substituted.
  3. The Infant with Recurrent Vomiting and Poor Weight Gain, Irritability, Apnea or Apparent Life-threatening Events (ALTE), Asthma or Pneumonia:
    Currently there is insufficient pediatric evidence to establish the optimal medical therapy in patients with significant complications of GER disease. Infants who are underweight due to GERD may gain weight when the caloric density of their feedings is increased. Antireflux surgery is considered in patients with persistent asthma and recurrent pneumonia, patients requiring prolonged medical therapy and patients with nonrespiratory complications of GER such as persistent vomiting, vomiting with growth retardation and severe esophagitis.
  • Formula Thickening Recipe
    • 1 Tablespoon rice cereal added to 2 ounces formula = 27 calories/ounce


  1. Pediatric GE Reflux Clinical Practice Guidelines. Journal of Pediatric Gastroenterology and Nutrition, 2001, Vol. 32, Suppl. 2. S1-S31
  2. Horvath A,Dziechciarz P,Szajewska H.The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials.Pediatrics. 2008 Vol 122, No 6:e1268-77.
  3. Pediatric GE Reflux Clinical Practice Guidelines. Journal of Pediatric Gastroenterology and Nutrition, 2001, Vol. 32, Suppl. 2. S7-S8

[back to top]