By Sr Teresa Hayward (RN, RM, Lactation consultant, Infant & Paediatric Nutritionist, Baby Sleep Consultant)
Reflux, spitting up or possetting are all names used to describe babies bringing back some of the milk that they swallowed earlier. Some spitting up is quite normal in young babies, this may simply be how they deal with too much milk or anything that doesn’t agree with them. This article looks at the reasons babies have reflux and answers frequently asked questions.
How common is reflux in babies?
Reflux is very common in young babies. Infants with reflux are generally happy and thriving babies who spit up at least once or more per day most days and are sometimes referred to as “happy spitters”.
What is silent reflux?
Silent reflux (laryngopharyngeal reflux) is the name coined for when regurgitated milk comes part way up the oesophagus towards the voice box and back of the throat then goes back down to the stomach without any spilling out of the mouth. This could potentially interfere with breathing causing wheezing or coughing.
Why do babies have reflux?
Immune system protection
Spitting up regularly may have a protective function if the baby is otherwise happy and gaining weight:
Breastmilk is full of immune factors (not just antibodies, but dozens of factors that interact with each other) that protect the baby from invasion by bacteria and other microorganisms (fungi, viruses, etc.) by forming a protective layer on his mucous membranes (the linings of the gut, respiratory tract and other areas). This protective layer prevents micro-organisms from invading the body through these mucous membranes. A baby who spits up gets extra protection, first when the milk goes down to the stomach, and again when he spits it up.
Protection against over feeding
Babies consume a large volume of milk compared to their size. Combined with a small tummy and a short oesophagus (the tube that carries food from mouth to stomach) some of the milk simply spills back out through the mouth after a feed. This is likely a protective mechanism if a baby has too much milk at once.
Is reflux in newborns the same as “acid” reflux in adults?
No, most infant reflux and silent reflux is not acidic
Milk (human, formula, or cow) is quite alkaline, as opposed to acidic, and baby tummies themselves are low in acid, compared to child or adult stomachs. Half of all infants visibly spit up at least once per day. Even more babies experience silent reflux, which is when stomach contents spill only partway up the throat and go down again without coming out of baby’s mouth. Most infant reflux is not highly acidic and likely not uncomfortable nor damaging to esophageal tissues.
What causes excessive reflux in babies?
Although some spitting up is normal, and may prevent overfeeding and protect the gut, some babies have more reflux than others. Possible causes include:
1. Too much milk (oversupply of breast milk)
Babies may spit up more if they’re getting too much milk, this is not necessarily a problem for mother or baby. However, sometimes a baby who is getting too much milk might gain weight well but be uncomfortable and fussy, and his mother may constantly have engorged breasts and blocked ducts. Sometimes the flow of milk from the breasts can be very fast with oversupply, especially at the start of the breastfeed—causing a baby to gulp, gasp and choke or let go of the breast. How well a baby can handle milk flow can depend on whether he has a deep latch (the way a baby is attached at the breast), and the position they are held in. Your lactation consultant can check whether your baby’s latch, or positioning could be improved or whether any steps need to be taken to manage your supply.
2. Cows’ milk allergy and reflux
Studies have shown a link between reflux and having an allergy or intolerance to cows’ milk protein. There could also be a sensitivity to some other food allergen, excess caffeine or second hand smoke. If a mother tries removing dairy products or other known allergens from her diet, the symptoms of reflux will improve if food sensitivity is involved.
Other less popular theories include:
3. Immature sphincter muscle
Reflux is sometimes attributed to an immature or undeveloped sphincter muscle—a ring of muscle between the stomach and the oesophagus (food pipe) preventing spillage of the stomach contents.
4. Tongue movement
The tongue moving in the right direction may play a role in the swallowing reflex down the oesophagus and into the stomach and intestines. Being tongue tied could interrupt this reflex action and could lead to sluggish digestion, inflammation, gas, trouble pooping and may contribute to symptoms of reflux, or colic in babies.
5. Swallowing of air
Swallowing of air is sometimes said to be a cause of colic or reflux.
MORE SEVERE FORMS OF REFLUX
Most common reflux won’t require any medication but forms that may require treatment include:
Gastrooesophageal reflux disease (GORD/GERD)
A form of reflux in babies called gastro-oesophageal reflux disease (GORD or GERD) may cause pain and other problems but in most cases there are usually underlying disorders predisposing the baby to this form of reflux
Pyloric stenosis
In a small number of cases, reflux is a sign of something more serious such as pyloric stenosis—the narrowing of the exit from the stomach to the small intestine. A common symptom of pyloric stenosis is forceful projectile vomiting that can travel several feet across a room.
Inflammation
Some babies with reflux associated with allergy can suffer from an inflamed oesophagus causing discomfort and difficulty swallowing which may be helped by medication.
What is GORD or GERD?
The acronym for gastro-oesophageal reflux disease is GORD or GERD depending on where you are in the world and how you spell oesophagus. Sources suggest only one in 300 infants actually has GORD needing treatment, yet the number of babies given acid-reducing medication tends to be very much higher than this figure
Symptoms of GORD
There isn’t a set of symptoms that is definitely diagnostic of GORD in babies.23 Of the potential symptoms and signs associated with GORD many can have other causes making diagnosis difficult (see square brackets in list below). Symptoms may include:
Frequent spitting up. [Could be normal baby reflux]
Poor weight gain or weight loss [Could be due to breastfeeding management, not enough milk.]
Excessive crying or fussy and irritable during or between feeds. Back arching and twisting the neck between feeds may be seen (Sandifer’s Syndrome). [Unexplained crying during or between feeds can be from many other causes including hunger or problems breastfeeding.
Difficulty sleeping or lying flat. It is quite normal for babies to prefer to sleep in a parent’s arms.
Feeding difficulties such as pulling at the breast and fussing, refusing to feed or conversely, feeding continuously for comfort.
Frequent hiccups
Coughing, difficulty swallowing. Baby may have a sore throat, or inflammation to the oesophagus (oesophagitis) with gagging, choking, coughing, difficulty swallowing and may have hoarse sounding cries. May have frequent ear infections.
Breathing problems. GORD/GERD may contribute to chronic respiratory disorders for example asthma, pneumonia and possible apnea, cough and aspiration
HOW CAN I HELP MY BABY WITH REFLUX?
Rule out other causes of symptoms
When spitting up is accompanied by a fussing or crying baby it can be easy to assume that “reflux” is the cause. However, the fussing may have a separate cause and spitting up milk might be unrelated or simply be following on from a crying burst due to raised pressure on the stomach
Could baby be hungry?
A baby fussing during feeds, pulling at the breast, refusing the breast, not wanting to lie flat, or being fretful might typically be blamed on reflux but these same symptoms can be seen in the baby who is not getting enough milk or not gaining weight normally. Oversupply can also be confused with not enough milk and rigid approaches to a perception of “oversupply” can quickly become “not enough milk”
Tips to help a baby with reflux
Try frequent smaller breastfeeds rather than large feeds further apart.
Try keeping baby in upright positions for feeding and carrying. A baby carrier or sling may be helpful for upright carrying as long as it doesn’t increase the pressure on the abdomen.
Avoid using a car seat or baby seat after feeds. Poor positioning can compress the stomach and increase reflux
Handle baby gently to minimize spitting up.
Elimination diet. If symptoms of allergy are present alongside reflux, consider if an elimination diet could help.
If oversupply is suspected check latch, positioning and breastfeeding management with your breastfeeding specialist
If formula fed assess whether baby is on correct formula
Burping your baby regularly may help prevent milk travelling back out with gas bubbles.
Comfort sucking on an empty breast.
Massage. Some parents have felt that baby massage helped with their babies’ symptoms of colic and reflux.
Medication
Medications such as alginates and antacids are often prescribed. Alginates eg gaviscon help to prevent stomach contents from moving back up the oesophagus. In adults, antacids reduce the acidity of gastric secretions and offer short term acid reduction and symptom relief for GERD. However, as discussed above, most baby reflux is not acidic and medication will not be helpful for normal reflux.
In the case of infants, most reflux is buffered by frequent feeds and seldom is of acid pH, which seems to have been largely ignored by prescribers of medication.
The largest randomized, controlled study to date in infants showed that for symptoms purported to be those of GERD, a PPI [proton pump inhibitor] such as Nexium was no better than placebo.
In addition, adverse events associated with some medications may outweigh their benefits
Reflux medications and simple antacids may cause constipation in babies
Reflux medications may affect protein digestion and result in food intolerances.
Suppressing normal acid secretions can have health implications such as gastroenteritis, or necrotizing enterocolitis in preterm babies
There may be an increased risk of developing asthma or respiratory tract infections
Acid suppression therapy early in life is linked to an increased risk of fractured bones.
If medication for GORD doesn’t help, and there are no medical concerns, contacting a lactation consultant may help rule out any other causes for fussiness that may be connected to breastfeeding.
Continue breastfeeding
Substituting breast milk for formula is unlikely to help reflux and is likely to make the symptoms worse.
What about thickened feeds, colic remedies and probiotics?
Thickened feeds and ANTI REFLUX formulas are not recommended
Colic remedies no better than placebos.
Probiotics, an unlikely cure
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