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Managing Chronic Health Needs in Child Care and Schools—Gastroesophageal Reflux Disease (GERD)

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What is gastroesophageal reflux disease (GERD)?

  • Gastroesophageal reflux (GER) is a condition in which stomach contents go up into the esophagus (the tube that connects the mouth to the stomach). This occurs commonly in babies and tends to improve as the infant gets older, but sometimes it is severe or does not improve with time.

  • When GER causes symptoms in babies other than spitting up, it is called gastroesophageal reflux disease (GERD). Worrisome symptoms include

    • Forceful vomiting

    • Vomiting blood or green-tinged bile

    • Excessive irritability with feeds

    • Breathing problems associated with feeding

    • Failure to gain weight

    • Recurrent pneumonias or asthmas not responding to medications

How common is it?

  • Spitting up is very common in infants, but most infants do not have complications and will outgrow the condition quickly.

  • When the symptoms do not improve over time and become a problem, it is considered to be a disease. It is difficult to estimate how many children have the official diagnosis of GERD.

What are some characteristics of children with GERD?

  • Symptoms of GERD could include abdominal or chest pain, breathing problems, irritability, unexplained anemia, difficulty swallowing, or hoarse voice, especially in the morning.

  • In older children and adults, these symptoms prompt people to seek medical attention and by definition they have GERD.

  • Gastroesophageal reflux disease peaks at 2 to 4 months of age and usually starts improving at 6 to 12 months of age as the child learns to sit alone. Sometimes older children and adults have GERD as well. Older children may be able to mention these symptoms, but babies cannot express them.

  • Babies tend to have symptoms such as back arching, irritability, spitting up, nasal congestion, and cough or wheezing. Some babies can even stop breathing (apnea) or have a slow heart rate because of GERD.

What adaptations may be needed?


  • Different kinds of medications may be used to block the stomach acid from causing irritation to the esophagus (food pipe).

  • Some medications block the production of stomach acids.

  • Some of these are available over the counter (OTC) and some are prescribed. The child’s primary care provider or specialist (eg, pediatric gastroenterologist) should be supervising any of these treatments in babies or young children.

  • Antacids neutralize stomach acid. Most of these are available OTC. These medications usually have no serious side effects.

Dietary considerations

  • To keep the stomach from being full and triggering the backflow of food, feeding smaller meals on a 3-hour schedule can help.

  • Some people find that thickening a baby’s formula or expressed breast milk with rice cereal helps. Sometimes the nipple will need to be enlarged a little to allow the flow of the formula, but it shouldn’t be wide enough to allow the baby to gulp the formula too quickly.

Physical environment

  • Upright positioning on a slope that does not increase pressure on the abdomen for 30 to 60 minutes after feedings; burping before, halfway through, and after the meal; and avoiding tight diapers can help infants with GERD.

  • Research shows that all babies, including those with GERD, are safer if they sleep on their backs. They should never be placed to sleep on their stomachs or sides.

  • Older children should avoid clothing that puts pressure on the abdomen and shouldn’t lay down for a nap immediately after eating.

What should be considered an emergency?

Babies with GERD can choke; a bulb syringe should be available to help clear the airway if necessary. If the baby is coughing, nothing should be done because the cough is the most effective way to clear the airway. If the baby stops breathing or making any sound, CPR techniques for infants should be used. These maneuvers are covered in pediatric first aid with CPR courses such as the American Academy of Pediatrics course, Pediatric First Aid for Caregivers and Teachers.

What types of training or policies are advised?

  • First aid to clear the airway for choking.

  • Feeding techniques including upright positioning and frequent burping.

  • Nutrition consultation on preparing thickened feeds may be helpful.

  • Feeding therapy consultation may be helpful.

  • Medication administration if medications are to be given while in care.

What are some resources?

Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, 2nd Edition, standards 4.007, 4.009, and 4.011 through 4.021

Source: Managing Chronic Health Needs in Child Care and Schools: A Quick Reference Guide.

Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics.

Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright © 2010 American Academy of Pediatrics. All rights reserved.

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