{"id":25593,"date":"2026-02-27T14:19:00","date_gmt":"2026-02-27T13:19:00","guid":{"rendered":"https:\/\/babywellnessfoundation.org\/?post_type=news-approfondimenti&p=25593"},"modified":"2026-02-27T14:20:16","modified_gmt":"2026-02-27T13:20:16","slug":"gastroesophageal-reflux-in-the-newborn","status":"publish","type":"news-approfondimenti","link":"https:\/\/babywellnessfoundation.org\/en\/news-approfondimenti\/gastroesophageal-reflux-in-the-newborn\/","title":{"rendered":"Gastroesophageal reflux in the newborn"},"content":{"rendered":"

Gastroesophageal reflux (GER) in newborns is a very common phenomenon in the first months of life. It is defined as the retrograde movement of gastric contents toward the esophagus and the oral cavity<\/strong>, which frequently occurs without pathological implications. This physiological event should not be confused with gastroesophageal reflux disease (GERD), which is characterized by clinical complications such as pain, persistent irritability, feeding difficulties, or inadequate growth. While GER is generally a benign and temporary condition, GERD requires medical intervention to avoid more serious complications.<\/p>\n

\"\"<\/p>\n

Physiology of the infant gastrointestinal tract<\/span><\/strong><\/h5>\n

The gastrointestinal tract<\/strong> of the newborn has some anatomical and functional characteristics that explain the high incidence of reflux in the first months of life. In the newborn and infant, the Lower Esophageal Sphincter<\/strong> (LES<\/strong>), or Lower Esophageal Sphincter (LES) in English, is functionally immature and exhibits frequent relaxations<\/strong> independent of the swallowing act. These relaxations, called Transient Lower Esophageal Sphincter Relaxations (TLESR)<\/strong>, represent a physiological phenomenon and occur with a frequency of about one every one to two minutes<\/strong>. They allow the release of gastric air<\/strong>, but during these episodes, the ascent of small amounts of milk or gastric contents into the esophagus<\/strong>, determinando rigurgiti<\/strong>, even repeated throughout the day.
\nThis mechanism is considered the primary cause of physiological regurgitation in infants.<\/p>\n

 <\/p>\n

Liquid diet and esophageal protection in the infant<\/span><\/strong><\/h5>\n

The newborn’s stomach has a limited capacity<\/strong> and accommodates a liquid diet, primarily breast milk or formula. Since milk is less viscous<\/strong> than solid foods, it is easier for it to rise into the esophagus<\/strong>.
\nThe immaturity of the LES, combined with the liquid diet, favors an increased frequency of regurgitation, without necessarily implying pathological reflux. <\/strong>In the healthy infant, numerous micro-reflux episodes are therefore common<\/strong>, generally well tolerated and not associated with mucosal damage. This condition tends to resolve spontaneously<\/strong> with the progressive functional maturation of the LES, which occurs in most cases within 12\u201318 months of life<\/strong>.<\/p>\n

However, there is a peculiarity: the esophagus of the newborn and child is equipped with effective defense mechanisms<\/strong>, including saliva<\/strong>, rich in bicarbonate with a buffering function, rapid esophageal peristalsis<\/strong> which promotes the clearance of refluxed material and a generally limited acid contact time<\/strong>, especially during wakefulness. These systems explain why, in the majority of cases, gastroesophageal reflux in pediatric age does not cause clinically significant lesions.<\/p>\n

\n

During deep sleep<\/em><\/strong> a reduction in saliva production and swallowing frequency is observed, with a consequent prolongation of the time the gastric contents remain in the esophagus<\/strong>. In predisposed children, this condition can favor the appearance or accentuation of symptoms such as nighttime irritability, cough, more persistent regurgitation, and sleep disturbances.<\/em><\/span><\/p>\n<\/div>\n

 <\/p>\n

Distinction between physiological and pathological gastroesophageal reflux<\/span><\/strong><\/h5>\n

International and national guidelines emphasize the importance of distinguishing between<\/strong> physiological and pathological reflux<\/strong> to avoid overdiagnosis and invasive treatments in infants with simple episodes of regurgitation. A newborn with gastroesophageal reflux (GER)<\/strong> can be classified as physiological or pathological based on the severity of symptoms<\/strong>, the frequency<\/strong> and the effects on the child’s general well-being<\/strong>.
\nThe difference<\/strong> between the two types of reflux is mainly based on clinical manifestations and complications.<\/p>\n

 <\/p>\n

Physiological gastroesophageal reflux (GER)<\/u><\/strong><\/span><\/h5>\n

Physiological reflux<\/strong> in newborns is an absolutely common condition, especially in the first months of life, and represents a natural phenomenon due to the immaturity of the gastrointestinal system. Le main<\/strong> features <\/strong>include:<\/p>\n

    \n
  • Manifestations<\/strong>: it generally presents with post-feeding regurgitation that can occur several times a day, without signs of significant distress.<\/li>\n
  • Symptoms<\/strong>: it is often asymptomatic or causes minor disturbances, such as small amounts of milk regurgitation immediately after the meal.<\/li>\n
  • Development<\/strong>: it has no negative impact on weight gain or the child’s well-being.<\/li>\n
  • Physiology<\/strong>: the immaturity of the lower esophageal sphincter (LES) and the supine position during sleep contribute to the ascent of gastric contents, which normally does not cause damage.<\/li>\n
  • Prognosis<\/strong>: most cases resolve spontaneously with growth, generally within 6-12 months, when the gastrointestinal system and the LES mature.<\/li>\n<\/ul>\n

     <\/p>\n

    Pathological gastroesophageal reflux (GERD)<\/u><\/strong><\/span><\/h5>\n

    Pathological gastroesophageal reflux (GERD)<\/strong> is a more serious condition that manifests when the reflux causes persistent clinical symptoms or complications that affect the health and well-being of the newborn. The main<\/strong> features <\/strong>include:<\/p>\n

      \n
    • Manifestations<\/strong>: associated with severe symptoms such as frequent vomiting, persistent irritability, inconsolable crying, refusal to feed, and difficulty in gaining weight.<\/li>\n
    • Symptoms<\/strong>: pathological reflux is often accompanied by extra-esophageal symptoms such as respiratory problems (chronic cough, wheezing, apnea) and marked irritability.<\/li>\n
    • Complications<\/strong>: it can lead to esophageal damage (esophagitis), failure to thrive, difficulty feeding and, in extreme cases, anatomical malformations (e.g. pyloric stenosis or esophageal anatomical abnormalities).<\/li>\n
    • Prognosis<\/strong>: pathological reflux may require medical treatment, such as medications to reduce gastric acidity or, in extreme cases, surgical interventions to correct anatomical malformations.<\/li>\n<\/ul>\n
      \n
      Symptoms to monitor to recognize GERD<\/strong><\/span><\/em><\/h5>\n
        \n
      • Constant vomiting and not just occasional regurgitation.<\/em><\/span><\/li>\n
      • Inconsolable crying during or after feeding.<\/em><\/span><\/li>\n
      • Difficulty feeding or refusal of milk.<\/em><\/span><\/li>\n
      • Delayed weight gain.<\/em><\/span><\/li>\n
      • Persistent respiratory signs, such as coughing or wheezing.<\/em><\/span><\/li>\n<\/ul>\n<\/div>\n

         <\/p>\n

        In summary, in physiological reflux, infants show intermittent regurgitation immediately after feeding<\/strong>, which does not cause severe symptoms or interfere with weight gain. However, when reflux is accompanied by persistent irritability<\/strong>, refusal to feed<\/strong>, poor weight gain<\/strong> or persistent respiratory symptoms, diagnostic investigation is necessary to exclude GERD or other underlying conditions.<\/p>\n

        Clinical studies suggest that fewer than 10% of infants with reflux require specific treatment<\/strong> or further diagnostic investigations, as most cases are physiological and tend to resolve spontaneously with growth. Pediatric guidelines, including those of the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), emphasize the importance of avoiding overdiagnosis and invasive treatments in infants with physiological reflux<\/strong>.<\/p>\n

        \u00a0<\/strong>\u00a0<\/strong><\/p>\n

        Postural positioning after feeding<\/span><\/strong><\/h5>\n

        Positioning the infant after feeding is one of the most important aspects in the management of physiological gastroesophageal reflux symptoms. Keeping the infant in a semi-upright position<\/strong>, with an incline of about 10\u00b0<\/strong>, uses gravity to promote gastric transit and limit the ascent of gastric contents into the esophagus. This measure can help alleviate primarily the respiratory symptoms<\/strong> associated with reflux, while not causing a significant reduction in the overall frequency of reflux episodes, which remain physiological.<\/p>\n

        The gravity<\/strong>, in fact, limits the height reached by the gastric contents, reducing acid contact with the upper portion of the esophagus<\/strong>, which is particularly sensitive to irritation. The containment of reflux at more distal levels contributes to reducing the risk of esophageal inflammation and associated symptoms such as pain, irritability and feeding difficulties.<\/p>\n

        \n
        Physiological mechanism<\/strong><\/span><\/em><\/h5>\n
          \n
        • In the newborn, the lower esophageal sphincter (LES)<\/strong> is immature and exhibits frequent transient relaxations (TLESR), which promote the reflux of gastric contents even in the absence of pathology.<\/em><\/span><\/li>\n
        • An incline of 10\u00b0 increases the gravitational component along the gastroesophageal axis, facilitating gastric emptying toward the duodenum<\/strong> and limiting the ascent of gastric contents.<\/em><\/span><\/li>\n
        • This approach does not necessarily reduce the total number of reflux episodes, but it modulates the extent and intensity of acid contact<\/strong> with the upper esophageal mucosa, reducing the risk of irritation and inflammation (esophagitis).<\/em><\/span><\/li>\n<\/ul>\n<\/div>\n

           <\/p>\n

          Scientific evidence<\/u><\/strong><\/span><\/h5>\n

          The main international guidelines and clinical studies recommending the maintenance of an upright or semi-upright position (10\u00b0\u201330\u00b0) after feeding in infants are:<\/p>\n

            \n
          • American Academy of Pediatrics (AAP, 2025)<\/strong>: suggests a semi-upright position post-feeding to reduce respiratory symptoms related to reflux, while reiterating that sleep must take place exclusively in the supine position on a flat surface to prevent SIDS.<\/li>\n
          • Italian Society of Pediatrics (SIP, 2024)<\/strong> and ESPGHAN\/NASPGHAN (2018-2022)<\/strong>: confirm that the semi-upright posture post-feeding promotes gastric emptying and limits acid contact with the upper esophagus in cases of physiological reflux, without indication for pharmacological therapy.<\/li>\n<\/ul>\n

            In clinical settings, it is commonly advised to keep the infant in an upright or semi-upright position for 20\u201330 minutes after feeding<\/strong>, in order to promote gastric emptying before sleep, while recognizing that direct evidence on the actual reduction of reflux episodes remains limited.<\/p>\n

            The guidelines<\/strong> NASPGHAN\/ESPGHAN<\/strong> do not recommend any positional therapy (including elevating the head of the bed or alternative positions) for the treatment of reflux symptoms during sleep, for safety reasons and lack of evidence of effectiveness. International bodies, including the World Health Organization<\/strong> (WHO) and the AAP<\/strong>, indicate the supine position on a flat surface as the only safe standard for sleep up to 12 months of age, in order to reduce the risk of Sudden Infant Death Syndrome (SIDS). The prone and lateral positions<\/strong>, although they may temporarily reduce reflux in pH recordings, are strongly discouraged for unsupervised sleep<\/strong> due to the increased risk of SIDS (American Academy of Pediatrics (AAP): Sleep Position and SIDS. <\/em>Pediatrics, 2025).<\/em><\/p>\n

            \n
            Conclusions<\/strong><\/span><\/em><\/h5>\n

            Gastroesophageal reflux in newborns is a very common phenomenon<\/strong> and, in most cases, a physiological condition related to the immaturity of the lower esophageal sphincter<\/strong> and the liquid diet of the first months of life.
            \nIn the majority of infants, it is a transient condition<\/strong> that tends to resolve spontaneously with growth, without the need for pharmacological treatment.
            \nAmong conservative measures, proper postural positioning<\/strong> after feeding can help reduce the intensity of symptoms<\/strong> by taking advantage of gravity. In this context, considering infant devices that allow for a controlled inclination of the support surface during the post-feeding awake period or supervised sleep <\/strong>promotes the newborn\u2019s comfort and appropriate postural support.<\/em><\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

            Gastroesophageal reflux (GER) in newborns is a very common phenomenon in the first months of life. It is defined as the retrograde movement of gastric contents toward the esophagus and the oral cavity, which frequently occurs without pathological implications. 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