Baby crying: GERD, silent reflux, allergy, or something else?
- Elise Armoiry My Baby Moon
- Dec 2
- 8 min read
Many parents worry about possible Gastroesophageal reflux Disease (GERD) when their baby cries or spits up. Some tell me their baby is on anti-acid medication and wonder about it. They also receive contradictory information on how often and at what rhythm to offer feeds in this context.
This article reviews the topic, especially in light of the latest recommendations from the HAS (1) (HAS is the French Assessment body on health practices)
Preliminary reminder: What is the purpose of gastric acid?
Gastric acid secretion in children is lower than in adults: it begins when the baby is hungry or smells milk. When milk enters the stomach, it triggers peristalsis of the digestive tract. In the stomach, secretions and gastric acid begin digesting milk proteins into amino acids and activate the enzyme pepsin, which contributes to the breakdown and release of minerals (calcium, iron). Then relaxation of the lower esophageal sphincter allows stomach contents to pass into the intestine. Gastric acid is therefore important because it enables the absorption of essential minerals and also kills germs.
Normal reflux: spit-ups
Reflux is a physiological mechanism in which stomach contents flow back into the esophagus after a meal. The amount spat up varies greatly between babies—sometimes it looks as though the baby has spat up an entire feeding, which can cause parental anxiety.
There is a peak at 4 months, with 50–85% of infants experiencing spit-ups at least once a day (2).
Mechanism (3):
When a baby drinks, sucking causes relaxation of the muscles in the lower esophageal sphincter (the stomach “door” opens). The milk is then digested by stomach acid and passes into the intestine. This takes about 45 minutes for breast milk and 75 minutes for formula.
Parents are often told that this valve is immature.
Indeed, it can open in situations other than sucking:
if the stomach is distended, for example by a large meal,
if the baby has swallowed air while feeding quickly (babies can also swallow air when crying): the air distends the stomach, which causes the valve to open,
abdominal pressure can also play a role (diaper changes after feeding, coughing, crying, bowel movements, tight clothing around the belly),
small throat contractions can also trigger relaxation of the valve,
gravity also matters: reflux is more frequent in a lying baby than in an upright adult.
The volume, consistency, and color of spit-ups can vary. Some babies will cry afterward (because it is uncomfortable), or want to feed again, without this being pathological.
Pathological reflux in infants (GERD)
Pathological reflux is defined as the presence of symptoms associated with reflux.
As stated in the HAS document (1): symptoms are non-specific. The main suggestive signs are:
persistent or excessive spit-ups associated with refusal to feed,
persistent unusual crying,
irritability during feeding,
poor weight gain or sleep disturbances.
HAS specifies: “Irritability or excessive crying, when isolated, should not lead to a diagnosis of pathological GERD in a child under one year old, especially if development is otherwise normal.”
2.1 Diagnosis
HAS differentiates physiological reflux from pathological reflux based on age of onset, visibility and timing of spit-ups (whether they occur far from feeding), appetite, growth curve, and warning signs:
blood in spit-ups (hematemesis) suggesting reflux esophagitis,
weight loss,
feeding difficulties (refusal to eat) or slowed growth associated with behavioral changes such as persistent, unusual crying or irritability,
onset of excessive spit-ups after 6 months of age or persistence beyond one year.
Complementary tests (such as pH monitoring) are rarely needed in children under 1 year.
2.3 Management and treatment
2.3.1 Non-drug management
In case of spit-ups, the following measures are recommended (4):
offer smaller, more frequent meals,
take breaks during feeds to help your baby burp and release swallowed air,
avoid laying your baby down right after a bottle; wait for a burp,
always place the baby on their back to sleep. Raising the head of the bed is no longer recommended—it does not reduce reflux,
during the day, avoid keeping your baby in a bouncer or car seat: this compresses the stomach and worsens reflux.
Feeding frequency:Some healthcare providers advise spacing feeds “to prevent constant digestion and allow the esophagus to heal.”
However, milk is a buffering substance: it neutralizes acid. Within 2 hours after a meal, stomach acidity is neutralized by the milk’s buffering effect (3).
This aligns with French (1,4) and UK (5) guidelines recommending smaller, more frequent feeds in reflux.
Thickeners: carob-based, starch-based, or AR formulaThickeners can reduce spit-ups and improve weight gain (2,6) but do not reduce acidity. Effects on crying and agitation are unclear.
HAS states: “If spit-ups remain troublesome despite reassurance and hygienic-dietary measures for at least two weeks, thickening infant formula is recommended for bottle-fed babies.”
Some breastfed babies are given thickener (e.g., Gumilk) before feeds to thicken breast milk in the stomach, or parents are told to pump milk to thicken it.
The 2017 Cochrane review (2) indicates that it is not possible to assess whether thickeners help breastfed babies (studies are on formula-fed infants).
HAS also states: “There is no indication to add bottles of thickened milk for exclusively breastfed infants, nor to pump and thicken breast milk.”
2.4.2 Drug management
Anti-acids: Gaviscon® (alginates):HAS: “In suspected pathological GERD after failure of hygienic-dietary measures, a short trial of sodium alginate (1 to 2 weeks maximum) may be considered, although evidence is limited.”
Gastric acid-suppressing drugs: H2 blockers (ranitidine), PPIs (omeprazole, esomeprazole)
A 2023 Cochrane review (7) evaluated these treatments. A placebo effect was observed, and the conclusion is that benefits are uncertain. HAS states: “The effectiveness of proton pump inhibitors has not been demonstrated in infant reflux.”
These drugs also have side effects:
Reduced acidity increases risk of infections, including respiratory and gastrointestinal (6,8)
Gaviscon may cause constipation
PPIs: headaches, nausea, digestive issues (1)
Possible increased allergy risk (9)
Possible fracture risk (3)
Many medical authorities (1,6) recommend using these medications only when justified; complementary tests may be needed to confirm pathological GERD.
In the UK, a breastfeeding assessment by trained staff is recommended for breastfed babies before considering treatment (5).
3. Is it really pathological reflux? Other possible causes for baby crying
For personalized support for crying and breastfeeding, you can book an appointment with Elise (trained by Dr Pam Douglas).
As noted earlier, some signs of pathological reflux (crying and irritability) are non-specific and may occur in other situations:
3.1 Cow’s milk protein allergy (CMPA)
See this article
It can cause the same symptoms as pathological GERD. Incidence is 2–3% in the first year (1). Family history and other signs (eczema, diarrhea, blood in stool) can guide diagnosis. Diagnosis is often done via elimination-reintroduction of cow’s milk proteins (for breastfed babies, the mother does the elimination diet). HAS recommends a maternal elimination diet (or special formula) and reassessing diagnosis if ineffective after 2–4 weeks.
3.2 Breastfeeding management in the context of frequent crying and slow weight gain
Breastfeeding management may need review. Most babies feed from both breasts 8–12 times per 24h. If feeds are fewer and parents were told to space them to avoid “constant digestion,” the baby may simply be hungry, especially if weight gain is under 30 g/day.
3.3 Oversupply (lactation excess) with lactose overload (3,9)
This can lead to frequent spit-ups, crying after feeds (or during), and very frequent feeds. In this context, alginates reduce spit-ups that would have relieved the baby, making discomfort worse. Adjusting milk supply can improve symptoms.
3.4 A physiological cause for crying, frequent waking, and spit-ups
These are often the symptoms leading to suspicion of reflux.
IBCLC Carol Smyth (3) describes another interpretation: PURPLE Crying, observed in 1/5 of babies, especially in the second month, decreasing between months 3–5. In France this is called evening crying or “décharge,” often wrongly termed “colic.”
PURPLE:P = peak,U = unexpected,R = resist soothing,P = pain-like expression,L = long-lasting (up to 5 hrs/day),E = evening.
Dr Pamela Douglas (9), in the Neuroprotective Developmental Care approach, describes a period of major neuroplasticity from 1–4 months, when the brain is maturing rapidly. Crying may be triggered very easily, even by minor stimuli, due to heightened stress response sensitivity. Babies can remain “stuck” in the crying spiral even after triggers have disappeared. For example, a baby who had difficulty latching may continue crying weeks after the issue is resolved.
Crying itself can cause spit-ups (6)—so it may be the crying that causes the spit-ups, not reflux causing crying.
She also notes that frequent spit-ups can be normal when the stomach is too full relative to its size.
According to her, arching backward and crying when put down are normal behaviors in infants who need high contact.
Arching and crying during feeding can also have various causes (breast instability, negative conditioning if pressure was applied to latch).
Likewise, frequent night wakings are normal; babies often sleep better close to an adult. Stress from not being near an adult may cause crying and spit-ups.
Emotional contagion (co-regulation) also matters: babies need a calm adult to calm down. But a crying baby increases parental stress, which then makes calming the baby harder, creating a vicious cycle. Considering this dynamic helps parents assess their own feelings and implement emotional regulation strategies:
If you are overwhelmed and at your limit: it is better to hand the baby to someone else or place the baby safely in their bed and take a moment to breathe or step outside before returning.
Pamela Douglas also proposes another possibility: some babies cry due to lack of sensory stimulation. Even moving from one room to another may be insufficiently stimulating for very alert infants who may then cry (and spit up). Outings or activities, with baby in a carrier or stroller, often help soothe crying.
Conclusion
Baby crying and spit-ups can worry parents and lead them to suspect pathological GERD, though causes may be multiple and physiological.
Recent recommendations from the Haute Autorité de Santé call for treatment only after diagnostic confirmation through complementary examinations.
In breastfeeding, it is sometimes possible to improve crying and spit-ups by reviewing breastfeeding management.
Are you a healthcare professional looking for breastfeeding training?Visit the Lactasource website
Disclaimer: This article is for general informational purposes only and is not a substitute for medical advice. Always consult a healthcare professional for questions about your personal situation.
References
HAS .Reflux gastro-œsophagien chez l’enfant de moins d’un an : définitions, prise en charge et pertinence des traitements pharmacologiques mars 2024
Kwok T, Ojha S, Dorling J. Feed thickener for infants up to six months of age with gastro-oesophageal reflux. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD003211. DOI: 10.1002/14651858.CD003211.pub2
Ouvrage « Why infant reflux matters » de Carol Smyth
Site Ameli. RGO du nourrisson : le diagnostic et le traitement. 2022
Davies I, Burman-Roy S, Murphy MS; Guideline Development Group. Gastro-oesophageal reflux disease in children: NICE guidance. BMJ. 2015 Jan 14;350:g7703. doi: 10.1136/bmj.g7703. PMID: 25591811; PMCID: PMC4707563.
Société canadienne de pédiatrie 2022 La prise en charge médicale du reflux gastro-œsophagien chez les nourrissons en santé
Tighe MP, Andrews E, Liddicoat I, Afzal NA, Hayen A, Beattie RM. Pharmacological treatment of gastro-oesophageal reflux in children. Cochrane Database of Systematic Reviews 2023, Issue 8. Art. No.: CD008550. DOI: 10.1002/14651858.CD008550.pub3.
Lassalle M, Zureik M, Dray-Spira R. Proton Pump Inhibitor Use and Risk of Serious Infections in Young Children. JAMA Pediatr. 2023 Oct 1;177(10):1028-1038. doi: 10.1001/jamapediatrics.2023.2900. PMID: 37578761; PMCID: PMC10425862.
Douglas PS. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry a lot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013 Apr;49(4):E252-6. doi: 10.1111/jpc.12153. Epub 2013 Mar 15. PMID: 23495859
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