Back Arching and Crying in Infant GERD
Yes, back arching during feedings combined with crying is recognized as a common symptom of GERD in infants and is thought to represent the non-verbal equivalent of heartburn. 1
Clinical Presentation of GERD in Infants
The American Academy of Pediatrics specifically identifies arching of the back during feedings as one of the common symptoms of GERD in infants younger than 1 year, typically occurring alongside other troublesome symptoms. 1
Key Symptom Patterns
Back arching with irritability is considered the infant's non-verbal way of expressing heartburn or esophageal discomfort that older children and adults can verbalize. 2 This presentation typically includes:
- Regurgitation or vomiting associated with irritability 1
- Feeding refusal or anorexia 1
- Presumably painful swallowing (dysphagia) 1
- Arching specifically during or after feedings 1, 3
- Poor weight gain 1
Important Clinical Context
However, back arching alone is not specific for GERD. Research demonstrates that back arching was not significantly increased in infants with pathologically confirmed GER compared to those without it (P = 0.30). 4 This means you must evaluate back arching in the context of other symptoms rather than relying on it as an isolated finding.
What Makes GERD More Likely
Parental perception that symptoms constitute a "problem" is most strongly associated with:
- Frequency and volume of regurgitation 5
- Increased crying or fussiness 5
- Reported discomfort with spitting up 5
- Frequent back arching 5
The combination of these features—not back arching alone—suggests pathological GERD rather than physiologic reflux. 5
Critical Differential Diagnosis
Before attributing back arching and crying to GERD, you must exclude other common causes of infant irritability: 2
- Cow's milk protein allergy (co-exists with GERD in 42-58% of cases) 2
- Neurologic disorders 2
- Constipation 2
- Infection 2
Red Flags Requiring Immediate Evaluation
Stop and investigate immediately if you see: 1, 3
- Bilious vomiting
- GI bleeding (hematemesis or hematochezia)
- Consistently forceful vomiting
- Fever
- Abdominal tenderness or distension
- Poor weight gain or failure to thrive
Diagnostic Approach
For most infants with back arching and crying, history and physical examination alone are sufficient to diagnose uncomplicated GERD—diagnostic testing is generally not necessary. 1, 6
When Symptoms Suggest Pathological GERD
Investigation and treatment should be primarily directed at infants presenting with: 4
- Frequent regurgitation (>5 times daily) - specificity 70.9% 4
- Feeding difficulties - significantly associated with pathological GER (P = 0.02) 4
In the absence of frequent regurgitation or feeding difficulties, pathological GER is unlikely (negative predictive value 87-90%). 4
Age-Related Considerations
Peak incidence of physiologic reflux occurs at 4 months of age (affecting ~50% of infants) and declines to only 5-10% by 12 months. 1, 3 Most infants "outgrow" overt GER by 7 months, and the majority resolve by 1 year without intervention. 5
Common Clinical Pitfall
Symptoms of GERD in infants do not always resolve with acid-suppression therapy, making symptom-based diagnosis particularly challenging in the first year of life. 1 This is why the diagnosis relies heavily on pattern recognition and excluding other causes rather than therapeutic trials.