Reflux and GERD in Premature Infants

woman feeding premature baby with bottle
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In This Article

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 NICU, but other babies will need long-term treatment.

Difference Between GERD and Reflux

In gastroesophageal reflux, or reflux for short, the stomach's contents come up out of the stomach and into the esophagus. When a baby has reflux, the milk may stay in the esophagus or the baby may spit up. Most cases don't cause any problems, and babies will usually outgrow it by their first birthday.

When reflux is severe and causes problems, it is called gastroesophageal reflux disease, or GERD. Many premature babies suffer from GERD that causes problems throughout the first year of life, and sometimes beyond.

Another term that parents may hear is "acid reflux." This occurs when the food or milk that comes back up into the esophagus is acidic. Acid reflux causes heartburn in children and adults, but babies usually do not have acid reflux since frequent milk feedings neutralize stomach acids.


Severe infant reflux 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 a feed. 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 severe reflux 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, severe reflux 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.

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    Article Sources

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