Clinical Practice Guidelines

Gastrooesophageal reflux in infants

  • See also

    Crying baby
    Reflux GOR fact sheet [Kids health info for parents website]


    Gastrooesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is a physiological process that occurs several times a day in healthy persons. Its clinical presentation of vomiting or regurgitation is very common in infants and in the majority of cases self-resolving and does not need treatment.  It may be associated with irritability but only very few "crying babies" will have significant GOR as the cause for their irritability. Reassurance of the parents is important (see parent information). 

    • peaks at 4 months of age when ~67% of healthy term infants have > 1 daily episode of regurgitation
    • between 6-7 months the prevalence of symptoms decreases from 61% to 21%
    • at 12 months of age only 5% have symptoms

    "Silent" reflux as GOR without vomiting/regurgitation is a controversial entity; certainly significant acid reflux (pH probe-proven) is always associated with vomiting

    Gastrooesophageal reflux disease (GORD) is GOR leading to complications. It is rare but more frequent in children with cerebral palsy, Down syndrome, cystic fibrosis and upper gastrointestinal malformations (tracheooesophageal fistula, hiatus hernia, pyloric stenosis). 

    The complications of GOR are 

    • oesophagitis 
    • failure to thrive 
    • aspiration

    The symptoms of GORD are vomiting with

    • pronounced irritability with arching
    • refusal to feed
    • weight loss or crossing percentiles
    • haematemesis
    • chronic cough,  wheeze
    • apnoeas

    GOR does not cause Sudden Infant Death Syndrome (SIDS).  However, GOR can be associated with an Apparent Life Threatening Event (ALTE).


    Investigations and treatment are normally not necessary, as GOR is a benign and self-resolving condition. Reassurance of parents is important (see parent information).

    If symptoms of GORD are present (see above) the child should be referred to General Medical Clinic within 1 week.

    All investigations for GOR (barium, scintigraphy, endoscopy and pH probe) have considerable limitations and should only be considered on an individual base after the patient has been assessed in General Medical Clinic.


    Don't encourage parents to change formulas.
    Never change a breastfed child to formula.

    Recurrent vomiting with symptoms of GORD

    • Exclude other reasons for vomiting (infection, obstruction, etc.)
    • Book urgent appointment in General Medical Clinic

    Recurrent vomiting with irritability

    As long as there is good weight gain and there are no symptoms of GORD, the most common cause will be a coincidence of a crying baby with simple GOR.  

    • Exclude other reasons for both vomiting and irritability (see  Crying Baby Guideline)
    • Reassure parents, apply general measures (see below), give parent information sheet ( see below)
    • If there are concerns that GORD is the cause of irritability (long duration, excessive):
      • Encourage Symptom Diary 
      • Book appointment in General Medical Clinic within 1-2 weeks
      • Consider acid suppressant therapy (see below)

    Simple recurrent vomiting ("happy spitter")

    • Exclude other reasons for vomiting (infection, obstruction, etc.)
    • Reassure parents, apply general measures (see below), give parent information sheet  ( see below)

    General measures:

    As mentioned above, GOR does normally not require any treatment.  However, GOR can be the cause of considerable parental distress.  Measures that may be considered include: 

    • Prone position after feeding. This has been shown to improve the symptoms of GOR.  However, this should only be done in awake children with parents present (never in sleeping or non observed infants because of the increased risk of SIDS)
    • Milk-thickening agents (eg rice cereal) reduce the number of episodes of vomiting but not the total time of oesophageal acidity.

    There is no evidence that the following measures make any difference in GOR but they also can be considered:

    • avoid exposure to tobacco smoke
    • avoid overfeeding
    • avoid aerophagia (swallowing of excessive air): bottle horizontal, appropriate teat
    • try smaller more frequent feeds (not <3 hourly)

    Acid suppressant therapy

    Both histamine-2 receptor antagonists (HRA, eg Ranitidine) and proton pump inhibitors (PPI, eg Omeprazole) produce relief of symptoms and mucosal healing.  PPI are superior and therefore the recommended therapy is:


    Under 10 kg: 5 mg once daily
    10-20 kg: 10 mg once daily (max 20 mg/day)
    Over 20 kg: 20 mg once daily (max 40 mg/day)


    Antacids, Surface agents

    Less effective than HRAs and PPIs and the metal contained in antacids (magnesium or aluminium hydroxide) and surface agents (sucralfate gel, alginates) make them unsuited for use in infants.

    Prokinetics (eg cisapride)

    Due to concerns about potential serious cardiac arrhythmias in patients receiving cisapride, prokinetics are no longer recommended for treatment of GOR.

    Surgical treatment

    Failure of medical therapy or recurrent respiratory symptoms (aspiration).
    Nissen fundoplication is the most widely used of the surgical procedures.


    Parent Information Sheet (HTML version)