Understanding Acid Reflux In Babies: What Should Parents Do

Dr. Rashmi Jain’s video on Signs of Acid Reflux in infants, How to manage them, and When to Seek Medical Attention

Symptoms of Acid Reflux in babies can be concerning for parents, especially if they happen a lot. It turns out, however, that gastroesophageal reflux in a baby’s first year of life is quite common and in itself, can be normal. We expect babies to spit up. There are circumstances, though, where spitting up accompanied by certain symptoms can signal a more serious problem. Below, we’ll address symptoms you might notice in the order of least worrisome to most worrisome. This way you’ll know if there’s “nothing to worry about” or if it’s time to call a doctor.

Symptoms of acid reflux in babies: what to watch for

Symptom #1: Your baby is spitting up a lot. (Least Worrisome for Doctors)

Like we discussed, a newborn spitting up after some or most of their feeds is completely normal. We expect that burp rag to get wet. Even if your baby is spitting up after every single feed or in between feeds, and there appears to be a lot of milk coming out compared to what you fed them, it might be normal. As long as the baby is gaining weight, seems comfortable, and tolerates their feeds, we call them “happy spitters” and monitor them for any change in symptoms. 

Why do infants spit up so much? Spitting up is common in newborns and persists through the first few months of life because of a few things:

Babies are still developing neuromuscular control of their lower esophageal sphincter (LES) muscle. This is a ring-like muscle between the bottom of the feeding pipe (the esophagus) and the top of the stomach. In an older child or adult, the sphincter tightens to keep food and fluid contents in the stomach and prevent them from passing back upwards into the esophagus. In babies, this muscle is still loose. Thus, breastmilk or formula can easily pass back into the esophagus and come out of the mouth along with a burp.

On top of that, the esophagus of a baby is short given they still have a smaller torso. As a baby gets taller, the length of the esophagus, or the distance between their stomach and mouth, also increases. Because of this shorter distance in infants, sometimes milk can come out of a baby’s mouth more easily, even ½ – 1 hour after feeding. As we noted above, if the child does not seem uncomfortable with this process, you can give the child time to mature and strengthen their neuromuscular control of this sphincter muscle.

Young babies who cannot sit or stand yet are almost always in a laying down position. In this situation, gravity cannot help prevent reflux in babies. Milk will naturally glide backward from the stomach into the esophagus when your child is lying down.

A baby is on a pure liquid diet. They have no solid contents in their diet that stay put in the stomach.

Thus, until a child is a few months old, develops neuromuscular control of the LES, starts spending more time in a seated rather than lying position, and begins having some solid foods in their diet, spitting up and reflux in babies will be par for the course and will be the least worrisome among the signs of reflux in babies.

Symptom #2: Your baby is experiencing some discomfort with infant reflux. (Your Baby Should See A Doctor) 

Certain things can help reduce symptoms of reflux in babies and make your baby more comfortable during and after their feeds. These are things we discuss at length when you book an appointment to see a virtual Pediatrician:

signs of reflux in babies

Offer smaller, more frequent feeds

Remember, your baby does not have control of that LES muscle to keep contents in their stomach. If we reduce the amount of milk that’s in their stomach, it’s less likely to flow upwards into their esophagus. Your baby will be hungry if you give them less with each feed, so you will have to feed them more frequently. They will be happier with each feed, though!

Position the baby Upright

Try not to lay your baby flat when you are feeding them. Hold them in your arms at a 20° to 30° angle so that gravity helps the milk flow downwards. Keep your baby in an upright position in your arms, on your shoulder, or in a swing for 20 to 30 minutes after a feed to help the milk or formula stay down towards the stomach as your baby digests. (This includes in the middle of the night, too!)

Burp the baby Frequently

If you let your baby take down an entire 2 to 3 ounces and then burp them, there is a likelihood that a lot of that milk will come out because it was trapped on top of an air or gas bubble. Initially, I recommend for newborns to burp after every 15 to 30 milliliters they consume. That’s every ½ – 1 ounce. As they get older, you can maybe stretch it to burping after every 1 – 1½ ounce. The more frequently you burp them and let that air out before more milk gets trapped above it, the more your baby’s comfort level will improve.

Use the correct nipple size

A nipple on a bottle that has too big or too small of a hole can be problematic. It will cause the baby to swallow more air that will get trapped in their belly and push more milk upwards into their esophagus. 

Change Mom’s diet

If babies are breastfeeding, it may be helpful to remove certain things in mom’s diet to keep the baby from becoming gassy, irritable, or intolerant of feeds. The biggest offenders tend to be dairy, soy, and eggs. If removing these things from mom’s diet improves the baby’s tolerance of feeds, this indicates that the baby may have a food allergy to one of these items. Babies do often work through food allergies with age, but not soon enough for moms to bring these foods back into their diet while they are breastfeeding.

Change their formula

If babies are formula feeding, I often change the formula to one that is lactose-free or one that has broken down proteins. I use a stepwise approach, and sometimes we will end up changing the formula a few times before your baby is comfortable with feeds. We also have to try a formula for a few days each time to see if it does the trick before changing the formula to something else.

Symptom #3: Your baby has projectile vomiting (Your Baby Needs Immediate Attention)

Among the more serious symptoms of acid reflux in babies is projectile vomiting or milk coming forcefully out of their nose. Vomiting can simply be due to the volume of your baby’s feeds, or it can be your baby’s response to the pain of stomach acid irritating the esophagus. At times, however, it may be a sign that their stomach isn’t able to pass the milk down further into their intestines for digestion. This situation might require hospitalization & surgery for correction. If we determine that this vomiting isn’t due to the latter situation, then we might manage this symptom in a similar way to what we have described above.

It is a more immediate cause for concern if your baby’s vomit is green, yellow, red, or has a coffee-ground appearance to it. This means bile might be coming up from the baby’s intestines or there might be blood in their vomit. This calls for immediate action and more than likely requires a referral to the ER or hospital for imaging studies & management.

symptoms of reflux in babies

Symptom #4: Your baby refuses to feed & looks like they’re not gaining weight. (Seek Medical Attention Now) 

It’s a major cause for concern if your baby is not eating to the extent that they’re not gaining weight. If it seems like your baby is dehydrated and hasn’t gotten enough fluid to make urine at least every 4 hours, this warrants a visit to the ER for a workup exam & IV hydration. If your baby is not dehydrated but is still refusing to feed, we may try some changes in their feeding regimen to see if that brings about improvement. The reason this situation is so urgent is that it doesn’t take a baby very long to become dehydrated & ill.

They need attention within hours if they’re not breast or bottle feeding


Finally, if your child is experiencing infant reflux, small droplets of acid or milk can go into a baby’s lungs and cause them to cough or choke. This can create inflammation in the lungs, which leads to wheezing or infection. This usually warrants certain imaging studies to help identify what is going on. Sometimes this irritation of the lungs will make them sick & keep them from feeding altogether. 

How to tell if it’s an emergency:

Your baby needs immediate attention and possibly a visit to the ER if they show the following symptoms with infant reflux:

  • They are inconsolably fussy  
  • Refusing to eat altogether
  • Baby is not making urine at least every 4 hours.
  • Baby has a fever greater than 100.4° Fahrenheit
  • Baby is very lethargic and they will not wake to feed 
  • Baby is projectile vomiting (green, yellow, red, or of a coffee ground appearance). 
  • There is blood in your baby’s stools. 

In Conclusion

It’s always important to be aware of warning signs of acid reflux in babies. After all, they can’t tell you when they aren’t feeling well. When it comes to spitting up, however, most often your baby is experiencing perfectly normal behavior that is of no concern. If you think your baby might have worrisome symptoms of infant reflux, don’t hesitate to contact BabiesMD with any of your questions and concerns. 

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