Acid Reflux in Children: Symptoms, Causes & Treatment

What Is Acid Reflux in Children?

Acid reflux (gastroesophageal reflux or GER) occurs when stomach contents flow backward into the esophagus. In infants, this happens because the lower esophageal sphincter (the muscle between the esophagus and stomach) is not fully developed at birth. Approximately 50% of babies under 3 months experience regular reflux, with symptoms peaking around 4 months of age.

The lower esophageal sphincter acts as a one-way valve that normally prevents stomach contents from traveling back up into the esophagus. In newborns and young infants, this muscular valve is immature and may not close properly, allowing milk and stomach acid to flow upward. This is why spitting up after feeds is so common in babies and is considered a normal part of infant development in most cases.

As children grow, the esophageal sphincter matures and strengthens, which is why reflux typically improves significantly by the time a baby reaches their first birthday. The transition to more solid foods and increased time spent in an upright position also contribute to the natural resolution of symptoms. By 18-24 months, the vast majority of children have outgrown their reflux completely.

It's important to understand that gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) are not the same thing. GER refers to the normal physiological process of stomach contents occasionally flowing back into the esophagus. GERD, on the other hand, is diagnosed when this reflux causes troublesome symptoms or complications that affect the child's health, growth, or quality of life.

Which Children Are at Higher Risk?

While reflux is common in all infants, certain groups of children have a higher likelihood of developing persistent or problematic GERD. Understanding these risk factors helps parents and healthcare providers identify children who may need closer monitoring or earlier intervention.

Children with neurological conditions or developmental disabilities have significantly higher rates of GERD. This includes children with cerebral palsy, Down syndrome, and other conditions that affect muscle tone and coordination. The neurological impairment can affect the function of the esophageal sphincter and the ability to coordinate swallowing effectively.

Premature infants are another group at increased risk, as their digestive systems are even less mature than full-term babies. The earlier the gestational age at birth, the higher the likelihood of significant reflux symptoms. Premature babies may also spend more time lying flat and have weaker muscle tone, both of which can worsen reflux.

Children who have had surgery on their esophagus or those born with congenital anomalies such as esophageal atresia or hiatal hernia often experience more persistent GERD. These structural abnormalities can permanently affect the function of the lower esophageal sphincter.

The Esophagus and How Reflux Causes Damage

The stomach produces hydrochloric acid to help digest food, and this acid is highly corrosive. The stomach has a protective lining that prevents damage from its own acid, but the esophagus lacks this same level of protection. When acidic stomach contents repeatedly flow into the esophagus, they can irritate and inflame the esophageal lining, a condition called esophagitis.

In children, esophagitis from acid reflux is relatively uncommon but can occur, particularly in those with frequent or severe reflux. Symptoms of esophagitis include pain with swallowing, refusal to eat, and in severe cases, bleeding that may appear as blood in vomit or dark-colored stools. When esophagitis is present, medical treatment is always necessary to allow healing and prevent complications.

Other Causes of Vomiting in Children

It's worth noting that not all vomiting in children is caused by reflux. Various conditions can cause regurgitation or vomiting depending on the child's age. In young infants, pyloric stenosis (a thickening of the muscle between the stomach and small intestine) can cause forceful, projectile vomiting and requires surgical treatment. Infections, food allergies, and intestinal obstructions can also present with vomiting.

What Are the Symptoms of Acid Reflux in Babies and Children?

The primary symptoms of acid reflux include frequent spitting up or regurgitation, heartburn (described as a burning feeling behind the breastbone), discomfort during or after feeding, and excessive fussiness. In infants, arching of the back during feeds and difficulty swallowing may also occur. Older children can describe heartburn and may complain of a sour taste in their mouth.

Recognizing acid reflux symptoms in children requires understanding how symptoms manifest at different ages. Infants cannot verbalize their discomfort, so parents must rely on behavioral cues and physical signs. Older children can describe their symptoms more clearly, which helps distinguish reflux from other digestive issues.

The hallmark symptom in infants is frequent regurgitation or spitting up after feeds. While some spitting up is normal, excessive regurgitation that occurs with every feed or between feeds may indicate more significant reflux. Some babies have "silent reflux" where stomach contents travel up the esophagus but are swallowed back down without visible spitting up - these babies may show signs of discomfort without obvious regurgitation.

Symptoms in Infants (Under 12 Months)

Beyond the visible spitting up, infants with significant reflux may display several behavioral and physical symptoms that parents should monitor. These symptoms can help distinguish between harmless spitting up and reflux that may need medical attention.

• Frequent regurgitation - bringing up milk during or shortly after most feeds
• Irritability during and after feeding - crying, fussiness, or appearing uncomfortable
• Arching of the back - especially during or after feeds, as if trying to escape discomfort
• Difficulty feeding - refusing to feed, pulling away from the breast or bottle, or feeding for only short periods
• Poor weight gain - not following expected growth curves or losing weight
• Hiccups and wet burps - frequent hiccups and burps that bring up liquid
• Gagging or choking - difficulty swallowing or appearing to choke during feeds

It's particularly challenging to identify reflux symptoms in babies who cannot communicate their discomfort verbally. A baby who cries excessively, particularly after feeds, or who seems to be in pain when swallowing should be evaluated by a healthcare provider. The presence of blood in vomit - which may appear red or look like coffee grounds - is always a reason to seek immediate medical attention.

Symptoms in Older Children (Over 2 Years)

As children grow and develop language skills, they can better communicate their symptoms. Older children with GERD often describe classic heartburn symptoms similar to adults. The ability to articulate these symptoms makes diagnosis somewhat easier in this age group.

• Heartburn - burning sensation in the chest or upper abdomen, often worse after eating or when lying down
• Regurgitation - sour or bitter taste in the mouth from stomach contents coming up
• Chest pain - discomfort in the middle of the chest, sometimes mistaken for heart problems
• Difficulty or pain with swallowing - feeling like food gets stuck or hurts going down
• Chronic cough - especially at night or when lying down
• Nausea - feeling sick to the stomach, particularly after meals

Some children develop respiratory symptoms from reflux, including chronic cough, wheezing, or recurrent episodes of bronchitis or pneumonia. This occurs when small amounts of stomach contents are aspirated (breathed into the airways). Children with asthma may find their symptoms are worsened by GERD.

What Can I Do at Home to Help My Child?

Parents can help reduce reflux symptoms through feeding modifications including smaller, more frequent feeds, keeping the child upright for 20-30 minutes after eating, and burping frequently during feeds. For formula-fed babies, thickened feeds may help. Older children should avoid eating close to bedtime and may benefit from elevating the head of the bed.

Many cases of infant reflux improve significantly with simple lifestyle and feeding modifications. These non-medication approaches are recommended as first-line management and can make a substantial difference in your child's comfort. The key is consistency - implementing these changes at every feed rather than occasionally.

The rationale behind these modifications is straightforward: by reducing the volume of stomach contents at any given time and using gravity to keep contents in the stomach, you decrease the likelihood of reflux episodes. These techniques are safe, have no side effects, and can be highly effective for mild to moderate reflux.

Recommendations for Infants Under 6 Months

The first six months of life typically see the highest rates of reflux, but this is also when simple changes can have the greatest impact. Work with your pediatrician to implement these modifications while monitoring your baby's growth and development.

• Feed smaller amounts more frequently - Instead of large feeds every 3-4 hours, offer smaller volumes every 2-3 hours. This reduces stomach distension and pressure on the esophageal sphincter.
• Keep baby upright during and after feeding - Hold your baby in an upright or semi-upright position during feeds and for at least 20-30 minutes afterward. Gravity helps keep stomach contents where they belong.
• Burp frequently - Pause to burp your baby after every 1-2 ounces of formula or when switching breasts during breastfeeding. This releases trapped air that can contribute to reflux.
• Consider thickened feeds - For formula-fed babies, your doctor may recommend adding rice cereal to bottles or using a pre-thickened anti-reflux formula. The thicker consistency helps the feed stay down.
• Check the nipple flow - If bottle-feeding, ensure the nipple flow is appropriate. Too fast a flow can cause the baby to swallow excess air; too slow can lead to frustration and gulping.

If you are breastfeeding, continue to do so. Breast milk is easily digestible and may actually protect against reflux. Some mothers find that eliminating dairy from their own diet helps if the baby has a concurrent cow's milk protein sensitivity. This dietary change should be discussed with a healthcare provider and monitored for effectiveness over 2-4 weeks.

Recommendations for Older Children (Over 6 Years)

For older children experiencing reflux symptoms, lifestyle modifications similar to those recommended for adults can be helpful. These children can often understand and participate in managing their condition.

• Elevate the head of the bed - Raising the head of the bed by about 15 centimeters (6 inches) using blocks or a wedge can help reduce nighttime reflux. Simply using extra pillows is less effective and can cause neck strain.
• Avoid eating late at night - The last meal should be at least 2-3 hours before bedtime to allow the stomach to empty before lying down.
• Limit trigger foods - Common reflux triggers include carbonated drinks, citrus fruits, tomato-based foods, chocolate, mint, and fatty or fried foods. Identify and reduce your child's specific triggers.
• Encourage healthy weight - Excess weight increases pressure on the stomach and can worsen reflux. If your child is overweight, work with your healthcare provider on a safe weight management plan.
• Avoid tight clothing - Clothing that constricts the abdomen can increase pressure on the stomach and worsen reflux symptoms.

Constipation can worsen reflux by increasing abdominal pressure. Ensuring adequate fiber and fluid intake, along with regular physical activity, helps maintain regular bowel movements. If constipation is a persistent problem, discuss treatment options with your healthcare provider.

When Should I Take My Child to the Doctor?

Seek medical attention if your child shows poor weight gain or weight loss, refuses to feed, has blood in vomit or stool, experiences persistent vomiting (especially projectile), shows signs of breathing difficulties, or appears in significant pain during or after feeds. These symptoms may indicate GERD requiring treatment or another condition needing evaluation.

While most infant reflux is harmless and resolves on its own, certain symptoms warrant prompt medical evaluation. Knowing when to seek care helps ensure that children with true GERD or other underlying conditions receive appropriate treatment without delay.

The distinction between "happy spitters" and babies with problematic reflux often comes down to whether the condition is affecting their growth, comfort, or overall health. A baby who spits up frequently but continues to gain weight appropriately, feeds well, and is generally content is unlikely to need treatment beyond lifestyle modifications.

You should contact your healthcare provider (but not necessarily seek emergency care) if you notice:

• Poor weight gain or your child is dropping off their growth curve
• Feeding refusal or significant reduction in feeding
• Persistent irritability, especially during and after feeds
• Chronic cough or recurrent respiratory infections
• Symptoms continuing beyond 12-18 months of age
• Symptoms significantly affecting quality of life

How Is Acid Reflux Diagnosed in Children?

Diagnosis typically begins with a detailed history and physical examination. Most children with uncomplicated reflux don't need testing. When investigations are needed, options include upper GI series (X-ray with contrast), pH monitoring (measures acid exposure over 24 hours), and endoscopy (direct visualization of the esophagus). These tests help distinguish GERD from other conditions and assess for complications.

The diagnostic approach to reflux in children differs significantly from adults. In most cases, a careful clinical history and physical examination are sufficient to diagnose infant reflux and guide initial management. Extensive testing is generally reserved for cases that don't respond to standard treatment, when complications are suspected, or when the diagnosis is uncertain.

When you visit your healthcare provider with concerns about reflux, expect a thorough discussion about your child's symptoms, feeding patterns, growth, and development. The doctor will ask about the frequency and timing of symptoms, what makes them better or worse, and whether there have been any concerning signs such as blood in vomit or feeding difficulties.

Upper GI Series (Barium Swallow)

An upper GI series is an X-ray examination that visualizes the esophagus, stomach, and upper small intestine. Your child swallows a contrast liquid (barium) that shows up on X-rays, allowing the radiologist to see the anatomy and watch how liquid moves through the digestive tract.

This test is particularly useful for identifying structural abnormalities that might be causing or contributing to reflux symptoms. It can detect conditions such as hiatal hernia, pyloric stenosis, intestinal malrotation, or strictures (narrowing) of the esophagus. However, the upper GI series is not the best test for diagnosing GERD itself, as it only captures reflux that occurs during the brief examination period.

Endoscopy (Gastroscopy)

Endoscopy involves inserting a thin, flexible tube with a camera (endoscope) through the mouth to directly visualize the esophagus and stomach. This procedure is performed under sedation so that your child sleeps through it and experiences no discomfort.

Endoscopy is the gold standard for detecting esophagitis (inflammation or damage to the esophageal lining from acid exposure). During the procedure, small tissue samples (biopsies) can be taken to examine under a microscope. This is important for confirming esophagitis and ruling out other conditions such as eosinophilic esophagitis (an allergic condition affecting the esophagus).

pH Monitoring and Impedance Studies

For more detailed assessment of reflux frequency and acid exposure, your child may undergo pH monitoring. This involves placing a thin probe through the nose into the esophagus, where it measures acid levels over a 24-hour period. Newer combined pH-impedance studies can detect both acidic and non-acidic reflux episodes.

These studies are most useful when the diagnosis remains uncertain after initial evaluation, when symptoms persist despite treatment, or when evaluating atypical symptoms such as chronic cough or recurrent pneumonia that might be related to reflux.

Evaluating for Cow's Milk Protein Allergy

In infants with persistent reflux symptoms, particularly those under one year of age, cow's milk protein allergy (CMPA) should be considered. This allergy can cause symptoms that overlap significantly with GERD, including vomiting, fussiness, and feeding difficulties.

The standard approach to evaluating for CMPA is an elimination trial: removing all cow's milk protein from the diet for 2-4 weeks and observing for improvement. For breastfed babies, this means the mother eliminates dairy from her diet. For formula-fed babies, a switch to an extensively hydrolyzed or amino acid-based formula is recommended. If symptoms improve significantly and return when dairy is reintroduced, the diagnosis is confirmed.

Celiac Disease Evaluation

In older children (typically over one year) with persistent reflux symptoms, particularly those with other concerning signs such as poor growth, chronic diarrhea, or abdominal bloating, celiac disease may need to be considered. Celiac disease is an autoimmune reaction to gluten that damages the small intestine and can present with various gastrointestinal symptoms.

Screening for celiac disease involves blood tests for specific antibodies. If these are positive, an endoscopy with intestinal biopsies confirms the diagnosis. It's important that the child continues eating gluten-containing foods until testing is complete, as a gluten-free diet before testing can lead to false-negative results.

How Is GERD Treated in Children?

Treatment depends on symptom severity and the child's age. Lifestyle modifications are first-line for all children. When medications are needed, acid-suppressing drugs such as proton pump inhibitors (PPIs) or H2 blockers may be prescribed. Children with esophagitis from acid damage always require medication treatment. Surgery is rarely needed and reserved for severe cases that don't respond to medical management.

The treatment approach for pediatric GERD follows a stepwise pattern, starting with the simplest interventions and escalating only when necessary. For most infants with uncomplicated reflux, lifestyle and feeding modifications alone are sufficient. Medications are reserved for children with documented GERD causing significant symptoms or complications.

It's important to understand that medications work by reducing stomach acid production, which decreases the damage acid can cause when it refluxes into the esophagus. However, these medications do not prevent the reflux itself - they simply make the refluxed contents less harmful. This is why lifestyle modifications remain important even when medications are used.

Acid-Suppressing Medications

When lifestyle changes alone are insufficient, acid-suppressing medications may be recommended. The two main classes used in children are proton pump inhibitors (PPIs) and H2 receptor blockers.

Proton pump inhibitors (such as omeprazole, lansoprazole, and esomeprazole) are the most effective acid-suppressing medications available. They work by blocking the enzyme that produces stomach acid, resulting in a significant reduction in acid secretion. PPIs are generally well-tolerated and are the treatment of choice for erosive esophagitis.

H2 receptor blockers (such as ranitidine and famotidine) are an alternative that reduces acid production through a different mechanism. While generally less potent than PPIs, they work more quickly and may be preferred for milder symptoms or for nighttime symptom control.

Treatment of Esophagitis

When acid reflux has caused visible damage to the esophageal lining (esophagitis), treatment with acid-suppressing medication is always necessary. The goal is to allow the esophagus to heal by reducing the acidity of any refluxed material. Most children with esophagitis require 8-12 weeks of treatment with a PPI, followed by repeat endoscopy to confirm healing.

In addition to medication, addressing underlying factors that worsen reflux (such as diet, feeding practices, and positioning) remains important. Once esophagitis has healed, many children can successfully discontinue medication, though some may require ongoing maintenance treatment.

Surgical Treatment

Surgery for GERD in children is uncommon and reserved for specific situations where medical management has failed despite optimal treatment. The most common surgical procedure is fundoplication, where the upper part of the stomach is wrapped around the lower esophagus to strengthen the esophageal sphincter and prevent reflux.

Candidates for surgery typically include children with life-threatening complications (such as recurrent aspiration pneumonia), those with severe symptoms despite maximum medical therapy, and some children with underlying conditions (such as neurological impairment) who cannot effectively manage their reflux with medications alone. The decision for surgery involves careful consideration of risks and benefits, discussed thoroughly with a pediatric gastroenterologist and surgeon.

How Can Children Be Involved in Their Care?

Children can and should be involved in their healthcare at an age-appropriate level. Older children can help track symptoms, understand their condition, participate in treatment decisions, and take responsibility for dietary modifications. Involving children in their care promotes better adherence to treatment and helps them develop health self-management skills.

There is no fixed age at which a child can begin participating in their healthcare - this depends on the individual child's maturity and understanding. However, even young children can be included in simple ways, such as being told what will happen during a doctor's visit or choosing between equally acceptable food options.

For older children and adolescents with GERD, involvement becomes increasingly important. A teenager who understands why certain foods trigger their symptoms is more likely to make good dietary choices independently. Similarly, a child who participates in discussions about their medication is more likely to take it consistently.

Healthcare providers should explain conditions and treatments in age-appropriate language, addressing the child directly rather than speaking only to parents. For complex conditions or when additional support is needed, language interpretation services are available to ensure that families who speak languages other than English can fully participate in their child's care.