Reflux and GERD in Premature Infants

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Gastroesophageal reflux is one of the most common, misunderstood, and difficult-to-treat problems that premature babies have. Many premature babies will outgrow reflux by the time they leave the neonatal intensive care unit (NICU), but other babies will need long-term treatment.

Difference Between GERD and Reflux

In gastroesophageal reflux, or reflux for short, stomach contents come back into the esophagus. When an infant has reflux, the milk may stay in the esophagus or the baby may spit up.

Reflux is a relatively common occurrence in infants. About 70% to 85% of infants spit up many times a day within the first two months of life. In 95% of cases, infants stop spitting up by the time they are 12-months-old.

When the reflux of gastric contents causes symptoms that affect the quality of life or pathologic complications it is referred to as gastroesophageal reflux disease or GERD. Many premature babies suffer from GERD that can cause serious health problems throughout the first year of life, and sometimes beyond.


GERD can cause a number of problems, especially in babies who were born premature and have other health problems of prematurity.

Symptoms of GERD in babies include:

  • Irritability: Babies with reflux may seem fussy or irritable, especially after feeding. They may seem to be in pain as stomach contents empty into the esophagus and are either swallowed or spit-up.
  • Feeding Intolerance: Feeding intolerance is a common symptom of GERD. Some babies may need to use a special formula that is already partially digested, to help their bodies digest more quickly and prevent leftover milk from coming back out of the stomach.
  • Poor Weight Gain: Premature babies in the NICU are fed a specific amount of milk calculated to ensure good weight gain. At home, though, babies with GERD may refuse feedings or take smaller amounts if they're in pain.
  • Chronic Lung Problems: GERD can make chronic lung disease worse, or can cause chronic lung problems. When food frequently regurgitates into the esophagus, it is sometimes possible for some of the food to be inhaled into the lungs. This irritates delicate lung tissue and may cause inflammation or cough.
  • Cardiorespiratory Events: In a few babies, GERD may cause apnea or bradycardia. Many NICU staff overestimate the number of apneic or bradycardic spells caused by reflux, and a number of studies have shown that the vast majority of babies with reflux do not have more apnea or bradycardia than babies without it.


Most of the time, GERD and reflux in babies are diagnosed by examination and by parents' and nurses' observation of symptoms alone. Extensive testing usually is not needed.


Treating GERD in babies can be very frustrating for parents and doctors alike. Although there are several different treatment options, none are perfect or will work for every baby.

  • Patience: Many premature babies will outgrow reflux by the time they leave the NICU. As babies grow, their stomachs stretch and are able to hold more food, and the body is able to digest food quickly and more efficiently. Although it can be hard for families to take a "wait-and-see" approach, this is often the best course of action.
  • Stomach or Side Positioning: Studies have shown that placing babies on their bellies or on their left sides after feedings can reduce the number of reflux events. Unfortunately, this type of positioning isn't practical as babies get closer to going home, as belly sleeping increases the risk of SIDS.
  • Elevated Positioning: Keeping an infant upright after feeds may help reduce symptoms. Although some babies have more reflux events if they're positioned upright, they may have fewer symptoms from these events if they're held upright after feeds or placed in a semi-reclined position. Young babies must always be watched in a semi-reclined position to avoid kinked airways.
  • Thickened Feeds: Thickening agents added to breastmilk or formula can sometimes help the milk to stay in the stomach. Although rice cereal or other thickeners added to milk may reduce vomiting, they don't reduce the overall number of reflux events.
  • Medication: Medications to treat reflux are some of the most commonly prescribed medications in the NICU, but a large number of studies show that these medications don't work and have harmful side effects. Metoclopramide (Reglan) can cause serious movement problems, and ranitidine (Zantac) has been associated with necrotizing enterocolitis (NEC) in preemies with immature digestive systems. Although both medications are common in NICUs, neither is very effective against reflux, especially in very young preemies.


While your baby is still in the NICU, try to be patient and to allow him or her to grow. Patience and time are the best cures in most premature babies.

If your baby is getting close to discharge and is still having a lot of reflux, talk to your baby's doctor about whether he or she needs treatment. If your baby is happy and growing well, then your simple home remedies may be all that's needed.

If your baby seems to be in pain, is not growing well, or is refusing food, then talk to your baby's doctor about developing a treatment plan. It may take time to hit on the right combination of positions, medications, and formula to help your baby, so persistence is key.

If your baby is one of the rare babies who have apnea related to reflux, you may need to take home an apnea monitor to keep your baby safe. Apnea monitors are used when a baby is sleeping and will alarm if a baby stops breathing or has bradycardia.

3 Sources
Verywell Family uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Czinn SJ, Blanchard S. Gastroesophageal Reflux Disease in Neonates and Infants. Pediatric Drugs. 2013;15(1):19-27. doi:10.1007/s40272-012-0004-2

  2. Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018;66(3):516-554. doi:10.1097/MPG.0000000000001889

  3. Baird DC, Harker DJ, Karmes AS. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children. Am Fam Physician. 2015;92(8):705-714.

Additional Reading
  • Clark, R and Spitzer, A. "Patience Is a Virtue in the Management of Gastroesophageal Reflux." Pediatrics Oct. 2009: 155, 464-465.
  • Di Fiore, J., Arko, M., Herynk, B., Martin, R., and Hibbs, M. "Characterization of Cardiorespiratory Events Following Gastroesophageal Reflux (GER) in Preterm Infants." Journals of Perinatology Oct. 2010: 30, 683-687.
  • Hardy, W. "Reducing Gastroesophageal Reflux in Preterm Infants." Advances in Neonatal Care June 2010: 10, 157.
  • Horvath, A., Dzlechclarz, P., and Szajewska, H. "The Effect of Thickened-Feed Interventions on Gastroesphageal Reflux in Infants: Systematic Review and Meta-analysis of Randomized, Controlled Trials." Pediatrics Dec. 2008: 122, e1268-e1278.
  • Malcolm, W., Gantz, M., Martin, R., Goldstein, R., Goldberg, R., and Cotten, C. "Use of Medications for Gastroesophageal Reflux at Discharge Among Extremely Low Birth Weight Infants." Pediatrics Jan. 2008: 121, 22-29.

By Cheryl Bird, RN, BSN
Cheryl Bird, RN, BSN, is a registered nurse in a tertiary level neonatal intensive care unit at Mary Washington Hospital in Fredericksburg, Virginia.