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.
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...
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.
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!
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...
*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.
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.
*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.
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.
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.)
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.
Before a diagnosis of GERD can be made a number of the following symptoms or behaviors would need to be evident.
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.
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.
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...
*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.
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.
Although commonly recommended, recent studies suggest elevating the head of the crib offers no significant benefit.
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.
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...
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.
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.
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.
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.
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.
Contact your baby's doctor should any unusual symptoms appear such as...
Written by Rowena Bennett
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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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.