Physiologic GER ('happy spitter') is normal in infants and resolves by 12–18 mo. GERD = reflux causing symptoms (poor weight gain, esophagitis, respiratory). Alarm signs = bilious or projectile vomiting, blood, FTT, fever, lethargy → workup for organic disease.
🚩 Red-flag clues (must not miss)
- •Bilious vomiting → malrotation
- •Projectile non-bilious in 3–8 wk old → pyloric stenosis
- •Hematemesis → erosive esophagitis, swallowed maternal blood, coagulopathy
- •Apnea, ALTE/BRUE associated with reflux → admit and monitor
Exam
- Growth chart, hydration
- Abdomen for olive (pyloric stenosis), distention
- Neuro for hypotonia (reflux is common in CP)
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Physiologic GER | Well thriving infant, resolves 12–18 mo | Reassurance, smaller more frequent feeds, upright after feeds |
| GERD | Poor weight gain, irritability, arching | PPI 4–8 wk trial; refer GI if no response |
| Pyloric stenosis | Projectile non-bilious, 3–8 wk, olive | US pylorus, electrolytes, surgery |
| Cow milk protein allergy | Blood-streaked stool, eczema | Hydrolyzed formula |
| Increased ICP | Bulging fontanelle, lethargy | Imaging |
| Malrotation | Bilious | UGI series urgently |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Famotidine | 0.5 mg/kg PO BID (max 40 mg/dose) | H2 blocker; tachyphylaxis common |
| Omeprazole | 1 mg/kg PO daily (max 20 mg) | Trial 4–8 wk, then re-evaluate; do NOT use long-term in well infants |
| Lansoprazole | 1.5 mg/kg PO daily (max 30 mg) |
Management / next steps
- Conservative first: smaller frequent feeds, upright 30 min after, hypoallergenic formula trial
- PPI trial only if true GERD (FTT, esophagitis, refusal)
- Avoid metoclopramide (FDA black box — tardive dyskinesia)
- Refer GI if no response to 4–8 wk PPI or alarm features