Reflux

What is reflux?
Should I be worried about my baby?
What causes reflux?
When spitting up is normal!
Symptoms of GER - physiological reflux
When reflux is a serious problem!
Symptoms of GERD - pathological reflux
How long does reflux last?
When spitting up is NOT due to gastro-esophageal reflux
What you can do to help
What tests are available?
What treatments are available?
When to see your doctor
How we can help!

What is reflux?

Gastro-esophageal reflux occurs when stomach contents are brought back up into the esophagus (food pipe), throat or mouth.

Infant reflux, gastric reflux, acid reflux, silent reflux, GER (gastro-esophageal reflux), GERD (gastro-esophageal reflux disease) and heartburn are all names that are commonly used to describe this condition.

Should I be worried about my baby?

Parents oftent worry unnecessarily when their healthy, thriving baby spits up (possets). For the majority of babies spitting up is not a condition that requires treatment, rather it is a phenomenon (a natural happening) that requires understanding.

Spitting up is classified under two different categories...

GER (gastro-esophageal reflux), due to physiological reasons i.e. normal bodily functions.
GERD (gastro-esophageal reflux disease), due to pathological reasons i.e. abnormal bodily functions OR disease.

It is estimated that approximately 50% of all healthy, thriving babies have 'reflux' and will spit up occasionally or regularly during the early months. 100% of all healthy babies will occasionally bring up milk into their throat and reswallow it; this is commonly referred to as 'silent reflux'. For babies, this believed to be a physiological response to protect against overfeeding.

Unlike adults, refluxing for babies is a normal body function and is rarely associated with 'heartburn'. Breastmilk (with a pH acid balance of 7.2) or infant formula (with a pH of 6.9) dilute the concentration of acid in a baby's stomach, so that when spitting up occurs there is no irritation of the esophagus (heartburn) and therefore no pain.

It is estimated that between 1 to 3% of babies experience problems associated with GERD (due to abnormal bodily functions or disease). GERD can affect babies in 3 different ways.

Esophagitis (heartburn) can occur if a baby refluxes so frequently at times when there is little milk content in the stomach, thereby bringing up stomach acid which has the potential to cause heartburn (inflammation of the food pipe). Untreated heartburn causes the baby extreme distress, day and night. Feeding difficulties are common due to the pain associated with swallowing.
Poor growth: The baby may struggle to gain weight or loose weight due to an inability to keep down sufficient quantities of milk to sustain healthy growth; or due to a feeding aversion associated with the pain of heartburn.
Respiratory problems can develop as a result of refluxed stomach contents entering the lungs. When respiratory problems are evident it is often difficult for medicos to determine if refluxing caused the respiratory problem or whether the coughing associated with the respiratory problem triggers the refluxing.

Unfortunately, the time when GER (i.e. spitting up due to normal infant body functions) in a healthy, thriving babies is most common, coincides with a time when approx 1/3 of all babies experience prolonged periods of irritability i.e. 2-16 weeks. This can be very confusing for parents and health professionals alike and as a result GER is often mistakenly diagnosed and treated as GERD.

What you should know!

Irritability and sleep disturbances in healthy, thriving babies are most often due to reasons unrelated to reflux.
Gastro-esophageal reflux does not make your baby immune to other problems suspected of causing infant colic. It's important not to dismiss other possibilities as the reason for distress simply because your baby happens to spits up (or not).
The incidence of reflux is significantly increased, for suseptible babies, when overfeeding occurs. (See Hungry Baby for common reasons why overfeeding occurs.)
Refluxing occurs day and night, therefore 'heartburn' is not confined to one particular time of the day.
GER will not respond to medications, because as a normal body function it does not require 'treatment'.
Antacids medications will not decrease a baby's irritability where irritability is due to reasons unrelated to heartburn.
Inappropriate use of antacid medications may prove harmful because stomach acid aids healthy digestion. The long term effects of giving infants antacid medications has not been fully studied.

What causes reflux?

Sphincter/valve immaturity

There is a ring of muscle (valve) at the top of the stomach which opens to allow fluid and food to enter the stomach, the valve then closes. In babies this valve frequently relaxes and opens at the wrong time and this allows milk and/or food to flow back up the esophagus, and possibly out of the mouth*.

Along with this lax valve, babies have a tendency to reflux because...

Babies have small stomachs.
Babies spend a lot of their time in a lying position.
Babies are fed mostly a fluid diet. (Milk can easily come up, particularly with a burp.)
Handling, such as diaper changing and bouncing can increase the pressure on a baby's full tummy, which then increases the risk of spitting up.

*Spitting up, possetting, spilling, throwing up, chucking up, vomiting, regurgitation, rumination and re-swallowing are some of the many words used to describe when milk is brought back up.

When spitting up is normal!

There is a wide range of different behaviors that can be described as normal when it comes to GER, due to physiological reasons. (Remember these babies are gaining good amounts of weight).

Your baby may spit up a tiny amount occasionally or he may throw up large amounts on a regular basis. Sometimes the milk may simply spill out of his mouth or at times the flow can be forceful and may even come out of his nose. Spitting up can occur shortly following a feed or anytime, even hours later (even while he's sleeping).

Your baby may reflux without spitting up, as small amounts of milk can rise up into his throat without coming out of his mouth. You can sometimes tell that this is happening because he might make swallowing noises. This is referred to as 'silent reflux'

Although, this condition is often called 'acid reflux', spitting up (or regurgitation) rarely causes heartburn, because frequent milk feeds dilute the concentration of acid in a baby's stomach. Most babies, particularly those who spit up milk, experience no pain and they continue to gain good amounts of weight despite the frequent spills. (However, they may be distressed for other reasons).

Some babies will squirm or cry and look uncomfortable, presumably because of the sour taste of the milk once it has been mixed with stomach acid and not necessarily because of a burning effect of heartburn. When this happens your baby may cry for a few minutes, in which case he may only require a little comforting until it passes. OR...

Your healthy, thriving baby may cry for hours and be irritable most of the day. In this situation he may (or may not) benefit from the use of thickened formula and/or antacid medications, see your baby's doctor for advice on medications. Where medications fail to relieve the distress of your healthy, thriving baby it is very likely that reflux is not the cause of your baby's distress and you may need to look for other reasons.

In deciding whether your baby requires treatment or not depends on whether reflux is causing him discomfort or if it is affecting his growth. Provided he's healthy and gaining enough weight, then reflux requires no treatment other than a few minor changes in feeding management and handling that may help to reduce the incidence.

Symptoms of GER - physiological reflux

Spitting up can vary from a little to a lot*.
Spitting up may be seldom or regular.
Your baby calms quickly following spit ups.
Your baby gains enough weight, possibly LARGE amounts of weight, as increased spitting up is frequently linked with over-feeding. (See Hungry baby for more on over-feeding.)

Irritability, sleeplessness and wakefulness are most likely to be due to other reasons. (See Crying baby and Infant colic.)

*Often the amount of milk brought up is far less than it looks. Even 1 oz can look like a huge amount when it comes from a small baby.

When reflux is a serious problem!

Only a tiny percentage of babies experience serious problems related to GERD, due to pathological reasons (i.e. abnormal body functions or disease), as opposed to a large percentage of healthy babies who experience GER, due to physiological reasons (normal infant body functions) who may also happen to be irritable and wakeful for other reasons.

Your baby may throw up such large amounts OR throw up so often that he fails to gain weight OR loses weight. Your baby may reflux so forcefully that milk shoots many feet across the room. Milk may be brought up in one huge vomit or he could vomit in continuous waves.

OR...

Your baby may experience extreme discomfort due to burning effects of heartburn, caused by prolonged and repeated refluxing of stomach acid (which causes irritation and inflammation of the esophagus). Babies may develop blood stained vomiting and occasionally difficulty swallowing. Esophagitis may cause your baby to scream inconsolably for hours. (Unlike infant colic where crying is often worse in the evening, the screaming related to esophagitis occurs multiple times during the day and night.) Feeding problems commonly develop because of this discomfort and this often affects the amount of weight gained. (Feeding problems also occur for many reasons unrelated to reflux.)

OR...

Although rare a baby may experience respiratory problems from stomach contents refluxing and entering the windpipe and lungs. Sometimes it is only while investigating the cause of recurrent breath problems such as wheezing, coughing or pneumonia that reflux is diagnosed.

If your baby is NOT gaining enough weight, screams for hours day and night, or if he has other symptoms such as vomiting blood or breathing problems, he needs a full medical assessment by a doctor and/or pediatrician.

Symptoms of GERD - pathological reflux

Before a diagnosis of GERD can be made a number of the following symptoms or behaviors would need to be evident.

The amount of milk spit up may be small or it may large and projectile (shoot out).
Some babies re-swallow (and not spit up) stomach contents which has been brought up into their throat or mouth.
Feeding problems such as screaming during feeding and/or refusing to feed are commonly associated with GERD (however GERD is not the only reason for feeding difficulties to occur).
Distress from heartburn/esophagitis is more likely if refluxing occurs at a time when there is little milk left in the stomach i.e. 1.5 to 2 hours after feeding.
Extreme distress (as opposed to fussiness or irritability) and prolonged inconsolable screaming (as opposed to consolable crying) occur frequently during the day and night. Rarely is this distress confined to one particular time of day.
Sleep disturbances: Short daytime naps and frequent awakenings overnight where your baby is unable to be comforted quickly. (There are also many reasons for disrupted sleep patterns that have nothing to do with GERD).
Blood in vomit (can be red or dark coffee color).
Repeated coughing or wheezing.
Repeated chest infections.
Breathing problems.
Failure to gain weight OR weight loss.

Back arching is commonly considered to be a sign of GERD. However, for infants younger than 3 months back arching is a sign of distress. Babies will also behave this way for reasons unrelated to pain or discomfort of GERD and therefore it is not a reliable sign of GERD.

How long does reflux last?

Reflux gradually improves with time as a baby's digestive system matures. For most babies spitting up has decreased remarkably by the age of 6 or 7 months and disappears completely by the age of 12 months. In severe cases it may persist for up to 18 months.

The amount and frequency of spitting up usually decreases once a baby is able to sit independently and/or once solid foods are introduced into his diet. For some babies, the amount of spitting up may increase again when they being creeping (crawling), due to once again spending time in a horizontal position, however this generally improves once the skill of walking is mastered.

When spitting up is NOT due to gastro-esophageal reflux

Spitting up can be due to a food or milk allergy or intolerance so it's important to observe for other symptoms as well. Additional gastric symptoms to watch for include...

Vomiting.
Abdominal bloating.
Cramps.
Excessive gas.
Diarrhea (frequent, watery bowel motions)*
Failure to gain weight OR loss of weight.
Diaper rash.

*Frequent watery bowel movements are very normal for healthy thriving breastfed infants and NOT necessarily a sign of a food or milk allergy or intolerance.

There are ALSO a number of other RARE conditions that can result in spitting up. Almost ALL of these can be easily ruled out by the simple fact that a baby is gaining healthy amounts of weight. A child that is failing to gain enough weight requires a thorough medical assessment.

What you can do to help

If your baby is otherwise healthy and thriving and experiences no (or minimal) discomfort as a result of reflux, he doesn't need any special treatment. However, you may find using some of the following strategies helpful to reduce the amount of spitting up.

Change diapers before feeding and not after, on a full tummy.
Feed your baby in a semi-upright position.
Slow down the feed (see How long to feed a bottle fed baby).
Avoid overfeeding (see Hungry baby for reasons why babies overfeed).
Burp your baby frequently during feeding (see Burping your baby).
Hold your baby in an upright position for 15 or 20 minutes following a feed; in a semi reclining position and not slumped forward (which will increase pressure on his full tummy).
Try thickened milk feeds (see Infant formula for details on thickening formula).
Avoid fruit juice or acidic fruits (see Carbohydrate malabsorption).
Discuss sleeping your baby on his tummy with your pediatrician. Although sleeping on the back is recommended in order to reduce the risk of SIDS, babies with severe GERD benefit from sleeping on their tummy. Only do this under doctor's orders.

Although commonly recommended, recent studies suggest elevating the head of the crib offers no significant benefit.

Solids

Although solid foods may prove helpful to decrease the amount of spitting up, early introduction of solids (babies less than 6 months) should not be used as a first line management, unless advised to do by your doctor. Solids can cause or complicate any feeding problems. Starting solids too soon can increase the risk of developing allergies.

PLEASE NOTE: Weaning a baby from breastfeeding to formula feeding does not improve this condition.

What tests are available?

Most babies with reflux will not require any diagnostic tests. A medical diagnosis is often made solely on the parent's description of their baby's behaviour. The condition is confirmed when symptoms improve following a successful a trial of medication.

If medications prove unsuccessful in a child who fails to gain sufficient weight, further investigation may be necessary. Test may include...

pH Monitoring

An acid sensitive probe is passed through the nose into the esophagus places in the child's esophagus. This measures the frequency and duration or reflux episodes by measuring the pH (acid) level of a 24-hour period. The information is collected electronically and analyzed by a computer.

Barium Swallow

The baby swallows a liquid containing barium, which shows up under X-ray. The liquid outlines the esophagus and stomach showing any narrowing.

Results from a barium swallow are not always accurate, because reflux does not occur all the time. Nor is it necessarily helpful for a healthy, thriving baby. Although a barium swallow may confirm a baby is refluxing, it does not identify if the baby is experiencing heartburn (esophagitis).

The main purpose of a barium swallow is to exclude other structural abnormalities that might cause vomiting. It is generally reserved for situations where a refluxing baby is loosing weight despite adequate milk intake.

Esophageal pressure testing (Manometry)

This measures how the muscles of the esophagus are squeezing.

Endoscopy

This is where a tube, which contains a small camera, is places into the child's esophagus, so that the doctor can see any signs of inflammation in the esophagus. It requires either sedation or a full anesthetic and is rarely performed on infants due to the invasive nature.

See University of Virginia Health System article for further details on the limitations of diagnositic tests.

What treatments are available?

Medications

The most common medical treatment for reflux is the use of antacid medications. These are used to reduce the effects of heartburn. Although many antacids can be purchased 'over-the-counter' most are not suitable for babies. An inappropriate use of antacids may be harmful.

There are also medications that can be used to speed up the movement of stomach contents into the intestines (in doing so reducing the amount of reflux). The benefits of these medications need to be weighed against the risk of possible side effects. Your doctor will be able to advise you on the appropriate us of reflux medications for your baby.

Surgery

In extreme cases, where a baby regularly throws up huge amounts and fails to gain weight OR suffers from esophagitis (inflammation of the esophagus) as a result of severe heartburn, surgery may be necessary.

When to see your doctor

Contact your baby's doctor should any unusual symptoms appear such as...

If your baby's vomit is green or blood stained.
If your baby frequent projectile vomiting.
If your baby fails to gain enough weight.
If your baby has other physical symptoms.

Written by Rowena Bennett
RN, RM, MHN, CHN, IBCLC, Grad Dip Health Promotion.

If you liked this article you will love Rowena's new book Your Sleepless Baby: The Rescue Guide. Most healthy, thriving babies have physiological reflux and are irritable due to problems that develop occur owing to an underlying sleep problems.

Added Nov 2003. Reviewed April 2004.

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If you would like to comment on this article or if you have a question regarding gastro-esophageal reflux that has not been covered in this article, feel fee to email us at info@babycareadvice.com.

How we can help!

Gastro-esophageal reflux is a treatable condition; if managed correctly it should NOT cause your baby considerable distress. If reflux treatment is not helping your thriving infant, this may be because the focus is not on the true cause of her distress.

Through the consultation service at Babycareadvice.com, one of our experienced consultants can help you to identify the source of your healthy (but distressed) baby's troubles. We achieve this by thoroughly examining every detail of your baby's feeding pattern and behavior, sleep and daily routine, until we discover the real reason for her distress.

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