Addressing Reflux in Babies

Reflux in babies is a common occurrence, but many parents find it to be a challenging issue to navigate. How much reflux is “too much”? When should parents become concerned?

Le Bonheur Children’s Hospital Gastroenterologist Maggie Vickers, MD, shares helpful information for parents and caregivers on how to effectively manage infant reflux.

Reflux Symptoms

Babies with reflux can experience a wide variety of symptoms, and some of these symptoms may even overlap with other conditions. From a gastrointestinal (GI) standpoint, babies with reflux often have with recurrent regurgitation of food, spitting up or vomiting, pain or discomfort or difficulty swallowing.

Accompanying complications include irritability, failure to thrive or poor growth or refusing to eat. Reflux might also affect the airway that can cause symptoms like wheezing, noisy breathing, cough or hoarseness.

Proper Digestion Mechanism vs. Reflux

When a person eats, food moves from the mouth through the esophagus, then into the stomach. The esophagus expands and contracts to move food to the stomach.

At the lower end of the esophagus, where it joins the stomach, is a circular ring of muscle called the lower esophageal sphincter. When food enters the top of the esophagus, the lower esophageal sphincter relaxes to allow food to enter the stomach and then closes to prevent food and acid from flowing backward into the esophagus.

Occasionally, the lower esophageal sphincter does not stay closed completely, or it can relax at the wrong time. This allows the liquids in the stomach to wash back into the esophagus causing an episode of reflux.

“Infants consume large amounts of milk and food relative to their small size and the small size of their stomachs. Their stomachs have poor compliance or stretchiness,” explains Dr. Vickers. “When presented with these large volumes, some of the gastric content will then reflux back into the esophagus.”

Understanding the Different Types of Reflux: GER vs. GERD

Dr. Vickers states that two main types of reflux can occur in infants: gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD).

Gastroesophageal reflux happens when contents from the stomach pass back into the esophagus with or without regurgitation or vomiting. This is normal in healthy infants and even children and adults. Most episodes are short in duration, meaning they last less than three minutes, occur after a feeding, cause few or no symptoms and are limited to the very bottom of the esophagus.

“The majority of babies are what we like to call ‘happy spitters’, meaning they eat well, they're growing well and they're healthy even though they spit up,” notes Dr. Vickers. “Spitting up really doesn't seem to bother them or cause discomfort. In these babies, spitting up is really more of a laundry problem than a health problem. It's important to remember that babies typically outgrow this by the time they're 12 to 14 months old.”

In contrast, GERD occurs when this reflux leads to troublesome symptoms that affect daily functioning or cause additional health problems for the child. Symptoms start to interfere with feeding and ultimately affect growth—causing poor weight gain or even weight loss and severe irritability.

When Should Parents Become Concerned?

70% of happy, healthy, thriving infants will spit up during their first three to seven months of life. Sometimes, this can occur several times a day because of the large volume of liquid they consume, their horizontal position—meaning they lie down most of the day since they can't sit up on their own—the GI tract is not fully developed yet and the limited capacity of the esophagus.

Reflux typically peaks at 4 to 6 months old. At 7 to 8 months old, the frequency and volume of spit up decreases, since the infant can now sit upright most of the day. 95% of spit up and acid reflux issues will resolve by 12 to 15 months old.

Where Dr. Vickers becomes concerned is when babies refuse feeding or experience trouble swallowing, vomiting—especially if it's forceful or contains blood or bile—poor weight gain or weight loss, severe irritability or breathing problems.

“Vomiting is different than simply spitting up in babies. Vomiting is forceful throwing up of stomach contents through the mouth, whereas spitting up is the easy flow of stomach contents out of the mouth. Frequently, this can occur with burping. Spitting up does not involve forceful muscle contractions, brings up only a small amount of milk and does not distress your baby or make them uncomfortable,” says Dr. Vickers.

Strategies to Mitigate Infant Reflux

The number-one strategy to mitigate reflux is to avoid overfeeding. Dr. Vickers recommends smaller amounts of milk more frequently, as well as burping more often throughout the feeding process. It’s also helpful to keep the infant upright for at least 30 minutes post-feeding and to limit active play immediately after.

“It would not be a great idea to do tummy time right after you have fed your baby,” she cautions. “It’s also important to avoid tight diapers or clothing or placing them in the car seat immediately after feeding. For infants who are on formula, you can try thickening feeds with added rice, cereal or oatmeal, starting at one teaspoon per ounce of formula, or try the commercial anti-reflux or added rice formulas, which have the added rice already mixed in.”

Dr. Vickers also advises parents who choose formula to have a conversation with their pediatrician about a two- to four-week trial of a special formula called extensively hydrolyzed formula, which can be easier to digest than standard formulas.

“This can help with reflux due to the effect on the microbiome and stomach emptying,” says Dr. Vickers. “It also helps some babies with vomiting and poor weight gain who may have something completely different, what we call a cow's milk protein allergy, rather than simply gastroesophageal reflux.”

If you have any concerns about your child, please do not hesitate to reach out to your pediatrician. They are more than happy to walk you through ways to help mitigate your child’s reflux issues, and if need be refer you to a gastroenterologist to help.