Reflux in Newborns

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. This article looks at the reasons babies have reflux and answers frequently asked questions.

How common is reflux in babies?

Reflux —full name gastroesophageal reflux (GER)—is very common in young babies. 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 (GORD/GERD) discussed below, the only problem with a lot of spitting up might be that you have more laundry to do.

Note: 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.

When will my baby grow out of reflux?

Reflux resolves for most babies by 12-15 months of age 5.

baby with reflux sleeps on his father's chest

Why do babies have reflux?

Immune system protection

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.

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 (Hassall, 2012). This is likely a protective mechanism if a baby has too much milk at once.

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 interfere with breathing causing wheezing or coughing.

Is reflux in newborns the same as “acid” reflux in adults?

No, most infant reflux and silent reflux is not acidic (Hassall, 2012). 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 breast milk washing up and down the oesophagus. It also ties in with studies that have not found acid reducing medication effective 6 7.

Maria’s story

Maria had plenty of breast milk and her baby, Seb, would constantly spit up milk after feeds regardless of whether he was held upright or lying down. There would always be a little pool of milk beside his head after a nap and his neck was always wet with milk. Before every breastfeed, Maria made sure she had plenty of towels ready to catch the over flow that would surely follow. Sometimes Seb would seem to bring back a whole feed and then breastfeed all over again. At times Seb would fuss when settled on his back but frequent burping (usually accompanied by more spitting up) made him more comfortable. Seb was a very happy, placid baby who loved to sleep and gained weight along the 97th centile. In this situation, Maria’s high volume of milk did not worry her or her baby—other than creating extra washing of towels and clothes due to spilled milk. The milk supply settled down on its own in time as did the reflux.

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. Theories for excess reflux include:

1. 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 contents8. 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. 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 (see Maria’s story above). 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. If you feel your baby’s reflux could be associated with oversupply or fast flow and it is causing difficulties with breastfeeding see our articles Oversupply of Breast Milk and What is a Fast Let-Down?

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 IBCLC 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.

3. Cows’ milk allergy and reflux

Studies have shown a link between reflux and having an allergy or intolerance to cows’ milk protein9. There could also be a sensitivity to some other food allergen, excess caffeine or second hand smoke 10. 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. 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). And formula does not contain any of the anti inflammatory factors, hormones or immune system support found in breast milk.

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. Author Alison Hazelbaker says 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 11.

5. Swallowing of air?

Swallowing of air is sometimes said to be a cause of colic or reflux. However lactation consultant Robyn Noble explains that most swallowed air is simply burped back up the oesophagus (and does not pass into the intestines to cause colic)12. According to one retrospective study with no control; poor tongue function (tongue-tie) and “lip-tie” could lead to excessive swallowing of air during breastfeeding leading to reflux. American surgeon Scott Siegel calls this aerophagia induced reflux (AIR)13 however more research is needed to prove this hypothesis as there were flaws in this study—see this critique (Facebook).

Are there severe forms of reflux needing treatment?

Most common reflux won’t require any medication but forms that may require treatment include:

Gastro-oesophageal reflux disease

A form of reflux in babies called gastro-oesophageal reflux disease (GORD or GERD) may cause pain and other problems 14 15 but in most cases there are usually underlying disorders predisposing the baby to this form of reflux (Hassall, 2012).

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. For more symptoms see Pyloric Stenosis from Birmingham Children’s Hospital NHS Trust. Pyloric stenosis is more common in formula fed babies16 and author Maureen Minchin says there is considerable evidence that it is due to inflammation and damage from cows’ milk.

Inflammation

Some babies with reflux associated with allergy can suffer from an inflamed oesophagus (eosinophilic esophagitis) 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 where you are in the world and how you spell oesophagus. Sources suggest only one in 300 infants actually has GORD needing treatment17 yet the number of babies given acid-reducing medication tends to be very much higher than this figure (Hassall, 2012).

Symptoms of GORD

There isn’t a set of symptoms that is definitely diagnostic of GORD in babies18. Of the potential symptoms and signs associated with GORD many can have other causes making diagnosis difficult. Symptoms can vary in severity and may include:

  1. Frequent spitting up or silent reflux
  2. Poor weight gain or weight loss (Vandenplas et al, 2009)
  3. Excessive crying or fussy and irritable during or between feeds, may having difficulty sleeping or lying flat. Back arching and twisting the neck between feeds may be seen (Sandifer’s Syndrome). Note: unexplained crying can be from several other causes and may not be due to abdominal pain (Hassall, 2012).
  4. 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 (Vandenplas et al, 2009). May have frequent ear infections 19.
  5. Feeding difficulties such as pulling at the breast and fussing, refusing to feed or conversely, feeding continuously for comfort. Note; similar symptoms can be seen with low milk supplyoversupply or a forceful let-down.
  6. Frequent hiccups (NHS, 2019)—symptoms that could also be associated with allergy (Palmer, 2015) or normal baby behaviour
  7. Breathing problems. GORD/GERD may contribute to chronic respiratory disorders for example asthma, pneumonia (BHL) and possible apnea, cough and aspiration (Vandenplas et al, 2009).

Lactose intolerance in babies

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 (Hassall, 2012). If you are not sure what is making your baby unhappy see Fussy Breastfed Baby. and always check with your baby’s doctor. An IBCLC lactation consultant can help you rule out feeding issues as a cause of fussing.

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 normally20Oversupply 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).

Ten tips to help a baby with reflux

  1. Try frequent smaller breastfeeds rather than large feeds further apart 21 .
  2. 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 22.
  3. Reclining positions. Conversely breastfeeding in a laid back position may help some babies (Wambach & Riordan, 2015)
  4. Handle baby gently to minimise spitting up
  5. Elimination diet. If symptoms of allergy are present alongside reflux, consider if an elimination diet could help.
  6. If oversupply is suspected check latch, positioning and breastfeeding management with your breastfeeding specialist
  7. Burping your baby regularly may help prevent milk travelling back out with gas bubbles
  8. Comfort sucking on an empty breast
  9. Massage. Some parents have felt that baby massage helped with their babies’ symptoms of colic and reflux 23
  10. Baby lying on his left side for a couple of hours after feeding may be helpful according to a review by Hammell24. The author notes more research is needed and side-lying after feeds should always be under supervision due to the increased risks of Sudden Infant Death Syndrome with this sleeping position.

Medication

Medications such as alginates and antacids are often prescribed—see NICE guidelines and the Breastfeeding Network in the UK has a reflux information sheet discussing reflux medications in more detail.  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. Hassall explains:

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] was no better than placebo.

In addition, adverse events associated with some medications may outweigh their benefits (Vandenplas 2009), for example:

  • Reflux medications and simple antacids may cause constipation in babies (Palmer, 2015 p 179)
  • Reflux medications may affect digestion and result in food intolerances (Minchin, 2015).
  • Suppressing normal acid secretions can have health implications such as gastroenteritis, or necrotising enterocolitis in preterm babies (Hassall, 2012)
  • Acid suppression therapy early in  life is linked to an increased risk of fractured bones25

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 worse26.

What about thickened feeds, colic remedies and probiotics?

Thickened feeds not recommended

Breastfeeding authors Wambach and Riordan discuss the drawbacks of thickening breast milk 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.

Colic remedies no better than placebos

The symptoms of colic (unexplained crying in an otherwise healthy baby)27 may appear to have similarities with reflux or silent reflux. Parents may come across suggestions to try gripe water or Infacol for a fussy baby (popular “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, an unlikely cure

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. 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.

Summary

Spitting up is a normal event for babies and doesn’t usually cause them a problem although more severe forms are possible e.g. GORD or GERD. Certain underlying causes such as allergy or oversupply 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.