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 12.
Reflux is very common
Reflux —full name gastroesophageal reflux (GER)—in newborns is very common. In Breastfeeding and Human Lactation3, the authors explain that infants with reflux are generally happy and thriving babies who spit up at least once or more per day most days. One study found 73% of babies spit up in their first month of life and that babies who were exclusively breastfed spit up less often than infants who received mixed feeding4.
Unless your baby has the more severe symptoms of gastooesophageal reflux disease (GERD) discussed below, the only problem with a lot of spitting up might be that you have more laundry to do.
Why do babies spit up?
Dr Jack Newman, Canadian paediatrician and breastfeeding expert explains how 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.
Vomiting due to illness or other medical reasons is not the same as reflux and will be more forceful and your baby will seem poorly, contact your health care professional if you have any concerns.
Causes of reflux in babies
Although some spitting up is normal, and may have a protective function, certain factors may worsen symptoms.
1. Immature sphincter muscle?
Reflux is sometimes attributed to an immature sphincter muscle5 which is said to strengthen as the baby grows through their first year 67. However author Linda Palmer describes this “immaturity” as a perfectly normal phenomenon considering 70% of babies have a “weak” lower esophageal sphincter saying: “This is not an error; it is normal”. And fellow author Maureen Minchin says the oesophageal sphincter is “beautifully evolved”.
2. Cows’ milk allergy and reflux
Studies have shown a link between reflux and having an allergy or intolerance to cows’ milk protein (Palmer, 2015). There could also be a sensitivity to some other food allergen, excess caffeine or second hand smoke (Kelly Bonyata, 2011). If a mother tries removing dairy products from her diet, the symptoms of reflux will improve if her baby is sensitive to cows’ milk protein. See Milk Allergy in Babies and Elimination Diet for further information.
If a baby is reacting to his mother’s diet it makes little sense to move to formula as an answer. The cows whose milk is modified into industrial formula also eat foods that could be potential allergens such as grasses (grains), corn, soy, or wheat (Palmer, 2015).
3. Fast flow and oversupply
Babies may spit up more if they’re getting too much milk (often called oversupply) or too much milk too quickly. If your baby gulps and gasps or lets go of the breast just after you have a let-down because the flow seems too fast for him, you could try taking him off the breast for a moment or two until the flow slows a little. A container or towel can catch the milk and once the flow has slowed your baby may be better able to cope with his feed. For more coverage on the subject of true oversupply and fast flow see #4 below and our article on oversupply.
4. Tongue function
How well a baby can handle milk flow can depend on whether they have a deep latch and a good tongue function. Your IBCLC lactation consultant can check whether your baby’s latch, positioning or tongue function could be improved or whether any steps need to be taken to manage your supply. The tongue moving in the right direction is thought to set the stage for the swallowing reflex down the oesophagus and into the stomach and beyond. Alison Hazelbaker says being tongue-tied could interrupt this reflex action and could lead to sluggish digestion, inflammation, gas, trouble pooping and may cause symptoms of reflux, colic or secondary lactose intolerance in babies 8. Poor tongue function may lead to excessive swallowing of air according to some practitioners. American surgeon Scott Siegel calls this aerophagia induced reflux (AIR) and calls for more research 9 10.
Is reflux in newborns the same as acid reflux in adults?
No, most infant reflux and silent reflux (when the regurgitated milk comes part way up the oesophagus then goes back down to the stomach) is not acidic 11. Author Linda Palmer explains:
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.
This ties in with Dr Jack Newman’s reasoning above that spitting up is probably beneficial (and normal) due to all the protective factors in breastmilk washing up and down the food pipe. Rarely, babies suffer from more severe forms of reflux. It also ties in with studies that have not found acid reducing medication effective 12 13.
Severe forms of reflux
- A rare form of reflux called gastro-oesophageal reflux disease (GERD) may cause pain and other problems 14 15 16.
- Some babies with allergy can suffer from an inflamed oesophagus (eosinophilic esophagitis) causing reflux and difficulty swallowing (Minchin, 2015).
- In a small number of cases, reflux is a sign of something more serious such as a blockage (e.g. pyloric stenosis17)
What is GERD?
The acronym for gastro-oesophageal reflux disease is GORD or GERD depending where you are in the world and how you spell oesophagus. Sources suggest only one in 300 infants actually has GERD needing treatment yet the number of babies given acid-reducing medication tends to be very much higher than this figure 18 19.
Symptoms of GERD
There isn’t a set of symptoms that is definitely diagnostic of GERD in babies20. Of the potential symptoms and signs associated with GERD many can have other causes giving potential for GERD to be over diagnosed. Symptoms often described include:
- Bringing up large amounts of milk after most feeds, or frequent burping or hiccups—symptoms that could also be due to allergy or normal baby behaviour.
- Poor weight gain or other feeding difficulties such as pulling at the breast and fussing, refusing to feed or conversely, feeding continuously for comfort—small volumes of milk are said to act like an antacid. Note; these symptoms are also seen with low milk supply.
- Being in pain or fussy and irritable between feeds, having difficulty sleeping, lying flat or waking with screams. Or back arching and twisting the neck between feeds (Sandifer’s Syndrome). Note: unexplained crying can be from other causes and may not be due to abdominal pain 21. Underweight babies can present as “fussy” due to hunger (see below).
- Associated breathing problems, chest infections, pneumonia, asthma, wheezing or apnea—note similar symptoms may sometimes be seen with allergies.
- A sore throat, or inflammation to the food pipe with gagging, choking, coughing or difficulty swallowing, may have hoarse sounding cries. May have bad breath or acid damage to teeth. Some of these symptoms could also be related to allergy or oversupply.
Fussy baby, hungry baby?
A baby fussing during feeds, pulling at the breast, refusing the breast, not wanting to lie flat, or being fretful can have other causes. A possible reason can be if your baby is not getting enough milk and is not gaining weight normally, and Dr Jack Newman notes that symptoms of reflux may be associated with low milk supply22. Oversupply and food allergy can also be confused with not enough milk and rigid approaches to a perception of “oversupply” can quickly become “not enough milk” (Newman, 2014). True oversupply can sometimes cause symptoms of lactose overload. Other causes for fussing in babies are described in Fussy Breastfed Baby. If you are not sure what is making your baby fuss, always check with your health professional and find an IBCLC lactation consultant to help you if it could be connected to feeding issues.
Frequent small feeds, keep baby upright, burp baby
General suggestions include:
- Upright positions for feeding, carrying and gentle handling. Try frequent smaller breastfeeds rather than large feeds further apart (Womanly Art of Breastfeeding, 2010)
- Conversely breastfeeding in a laid back position may help (Wambach & Riordan, 2015)
- Look at mum’s diet and consider if an Elimination Diet could help if allergies are involved
- If oversupply is suspected check positioning, tongue function and breastfeeding management with your lactation consultant
- Burping your baby regularly may help prevent milk travelling back out with gas bubbles
- Baby lying on his left side may be more comfortable (Minchin, 2015).
- Comfort sucking on an empty breast
Thickened feeds not recommended
Breastfeeding authors Wambach and Riordan discuss the drawbacks of thickening milk feeds to help reflux:
Occasionally providers will suggest thickened feedings with cereal. When cereal is added to breastmilk, enzymes break it down very quickly, and it is an ineffective thickening agent. Furthermore, thickened feedings have not been found to be effective. The frequency of reflux episodes may be reduced, but exposure of the oesophagus to acidic gaseous material is increased, probably because thickened gastric contents do not clear as quickly (Bailey et al, 1987). In addition use of cereal-thickened feedings is associated with coughing in infants with GERD (Orenstein et al., 1992).
Author Maureen Minchin describes thickeners as food additives carrying risks that should have no place in the treatment of complicated reflux. She shares that in 2012 commercial thickener “Simply Thick” was linked to the deaths of seven babies.
Medications such as antacids prescribed by your doctor can 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,19 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] was no better than placebo.
The Breastfeeding Network in the UK has a reflux information sheet discussing suitable medications when truly needed. However adverse events associated with some medications may outweigh their benefits (Vandenplas 2009). For example reflux medications and simple antacids can cause constipation in babies (Palmer, 2015 p 179) or may affect digestion and result in food intolerances (Minchin, 2015). If medication for GERD doesn’t help, contacting a lactation consultant may help rule out any other causes for fussiness that may be connected to breastfeeding.
The symptoms of colic (unexplained crying and tummy ache in an otherwise healthy baby)23 have similarities with reflux or silent reflux. Parents may come across suggestions to try gripe water or Infacol for a fussy baby (traditional “cures” for colic). Author Linda Palmer warns that gripe water may contain a lot of sugar and “cures nothing” and re simethicone drops (Mylicon, Infacol) she says studies indicate “they work no better than placebos”.
Probiotics are live bacteria and yeasts that are widely promoted as having health benefits when these “friendly bacteria” are added to our diet. There is more about probiotics generally on the NHS website which points out that there is little evidence for many of the health claims surrounding them. Could probiotics help reflux in babies? In her book Baby Poop author Linda Palmer says although probiotics may be useful for healing a baby’s damaged gut in certain circumstances, they are not a cure for colic and reflux. There is still much to learn about probiotics and how they could affect babies for better or worse. For a discussion of the pros, cons and unknowns about probiotics for babies see Are Baby Biotics Bugging You? by Maureen Minchin or her book Milk Matters which is reviewed here.
Some parents have felt that baby massage and cranial osteopathy helped with their babies’ symptoms of colic and reflux (NCT, 2017).
Spitting up is a normal event for babies and doesn’t usually cause them a problem although more severe forms are possible e.g. GERD. Certain underlying causes such as allergy, oversupply, lactose overload and poor tongue function can make reflux worse. Working with an IBCLC lactation consultant alongside your health professional can help find ways to reduce reflux or identify other possible reasons for an otherwise healthy breastfed baby to be miserable and fussy.