Reflux In Babies
Gastro-oesophageal reflux (‘reflux’ for short) is a normal physiological process whereby contents of the stomach come back up into the oesophagus (the tube connecting the mouth to the stomach). You’ve likely experienced reflux before (e.g. during pregnancy or after eating a spicy meal). But reflux in babies can pull on a parent's heartstrings, especially when it appears to be causing tears and discomfort.
Parents should know that reflux is common in normal, healthy babies. This is because various factors make it easier for stomach contents to come back up into the oesophagus of babies. Such factors include the fact that:
- Their diet is all liquid (at least for around the first 6 months)
- They spend lots of time lying down
- Their oesophagus is shorter than in adults
In babies, sometimes the milk that comes back up the oesophagus may spill out their mouth. This is known as spitting up or posseting.
For many families, reflux causes no real problems. If your baby is overall content, eating well and gaining sufficient weight, no treatment may be necessary. However, when the reflux causes problems, doctors may diagnose this as gastro-oesophageal reflux disease (GORD).
Here are 10 questions about reflux in babies answered.
#1: How Common Is Reflux In Babies?
Reflux commonly occurs several times each day in babies. It typically occurs soon after feeds, although it might also occur 1 to 2 hours after feeds.
Reflux tends to peak during the first month, with 73% of babies experiencing it in this time.
Reflux gradually tends to reduce to 50% by the fifth month.
#2: What Are Some Factors Which Can Increase Reflux In Babies?
Several factors seem to be associated with an increase of reflux in babies such as:
- Drinking too much milk and/or drinking it too quickly (e.g. due to an oversupply or overactive let-down reflex)
- Swallowing air during feeds. This might occur if a baby is very fussy at the breast and comes on/off (e.g. due to an older baby being distracted) or if a baby slips on/off the breast (e.g. due to a tongue-tie or overactive let-down reflex)
- Teething as babies may swallow more saliva than usual
- The introduction of solids or a new food
- Having a cold and swallowing more mucus
#3: Will My Baby Grow Out Of Reflux?
It’s likely reflux will largely disappear by 12 months of age. Only about 4% of babies still experience daily reflux by this age.
#4: When Is Reflux A Medical Problem?
If your baby is developing and growing normally, has no ongoing respiratory problems and does not experience pain with reflux, it’s likely more of a laundry problem than a medical one.
However, reflux can be a feature of a medical condition called gastro-oesophageal reflux disease (GORD) whereby a baby requires medical evaluation. It occurs in about 1 in 300 babies.
GORD encompasses a variety of medical conditions of gastrointestinal (e.g. pyloric stenosis), infective (e.g. urinary tract or ear infection, or gastroenteritis), respiratory (e.g. asthma) or other (e.g. cow’s milk protein sensitivity) origin.
#5: What Are The Main Features Of GORD?
Common signs that a baby with GORD has include:
- Spitting up large amounts of milk after the vast majority of feeds
- Very unsettled behaviour (moreso than what would be expected as normal given the baby’s age) and seems to experience pain with reflux. The baby may be extremely fussy with most breastfeeds or you may experience breast refusal
- Not gaining enough weight
- Persistent respiratory problems (e.g. aspiration pneumonia, chronic cough and wheezing)
Other signs of GORD (which can also occur in babies with simple reflux) include back arching after most feeds and hiccups. These signs can also be completely benign features of normal heathy babies too who are just going through an unsettled period.
Most of these signs can have other causes too, hence a medical diagnosis is required. If you are worried your baby might have GORD, see a doctor.
#6: Does How A Baby Is Fed Influence Reflux?
Babies who are exclusively breastfed tend to experience less reflux episodes each day as compared to partially breastfed babies.
Also, breastfed babies tend to experience GORD for a shorter time than formula fed babies.
#7: What are Some Tips To help Minimise Reflux?
There are various ways to help minimise reflux such as:
- Taking steps to manage an oversupply or overactive let-down reflex if relevant
- Optimising positioning and attachment to minimise air swallowing
- Keeping your baby more upright during feeds
- Offering smaller feeds more often (although some babies prefer larger feeds less often)
- Hold your baby in an upright position after feeds. Some suggest doing this for 20-30 minutes after feeds. For many babies even a few minutes can help
- Carrying your baby in a sling or other carrier
- Dressing your baby in loose clothing with her nappy fastened loosely around her tummy
- Handling your baby gently without jiggling her, especially soon after feeds
- Eliminate all cigarette smoke exposure, because this makes reflux worse
- Limiting caffeine intake while breastfeeding may help. Also, if a food sensitivity (e.g. to cows’ milk protein) is the cause of (or worsens) your baby’s reflux, eliminating this from your diet while breastfeeding can help (only do this under the guidance of a health professional such as a dietitian).
- Following your baby’s cues to try to work out what works best for her
#8: Do Thickened Feeds Have A Place In Reflux Treatment?
You may have heard about use of thickeners to treat reflux. The belief is by making the feed heavier, it would tend to stay in the stomach, rather than rising back up the oesophagus.
According to Australia’s National Health and Medical Research Council (NHMRC) thickening of feeds “has some benefit in decreasing the amount regurgitated but is not effective in decreasing the number of episodes of GOR [gastro-oesophageal reflux] or acid exposure, and thus has no real place in the management of complicated GOR.”
The NHMRC also indicates that feed thickeners have some negative effects, such as increasing the length of time it takes for feeds to pass through the stomach, which may even increase reflux. Thickeners can also increase coughing and constipation.
Practically speaking, milk that your baby drinks straight from your breast cannot be thickened. Thickening expressed breastmilk is difficult because live enzymes work fast to break down the starches that make up many thickeners.
It’s important not to give a baby thickened feeds unless advised by a doctor. Since GORD can be associated with medical problems, exclusive breastfeeding (i.e. without any thickeners, etc) is advisable whenever medically possible. This is because lack of exclusive breastfeeding carries risks.
Find out more in our article about thickened feeds.
#9: Are There Potential Risks Involved With Reflux Medications?
Common reflux medications include acid suppressant medication. However, there is a lack of evidence of their effectiveness in treating GORD.
There are several potential risks involved with suppressing stomach acid too. This is because stomach acid is important for several reasons, and suppressing it may contribute to various problems. For example, stomach acid is important for:
- Sterilising gut contents to prevent bacterial overgrowth in part of the digestive tract, which is not designed to be full of bacteria. Bacterial overgrowth can adversely affect nutrient absorption and cause diarrhoea
- Mineral absorption
- Stimulating gastric hormones responsible for releasing all the main digestive enzymes that act in the small intestine
There should always be an emphasis placed on lifestyle measures and reassurance to manage simple reflux and GORD. Pharmalogical management should be reserved for a small percentage of babies with complicated GORD which is not helped by lifestyle measures.
#10: Where Can I Get Support?
Dealing with reflux in babies can be exhausting and distressing for some families. Seeking support can help, especially if you are struggling. For example, you may find it helpful to contact the Reflux Infants Support Association, an Australian Breastfeeding Association counsellor or a La Leche League leader.