Understanding and Managing Infant Reflux: What Every Parent Should Know

Reflux, or gastro-oesophageal reflux (GOR), is a common condition in infants, affecting up to two-thirds of babies during their first year of life. In most cases, reflux does not harm your baby and typically resolves on its own by the time they turn one. However, for some infants, it can lead to discomfort or develop into gastro-oesophageal reflux disease (GORD), which may require medical treatment. This article explores the causes, symptoms, diagnosis, and management of reflux and GORD, as well as addresses frequently asked questions and provides practical advice to help parents keep their babies comfortable and healthy.

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What is Reflux?

Reflux, also known as gastro-oesophageal reflux (GOR), occurs when food or milk from the stomach flows back up into the oesophagus (food pipe) or mouth. Most of the time, this reflux is swallowed back into the stomach, but occasionally, your baby may spit it out, which is also known as spitting up, posseting, or regurgitation.

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What Causes Reflux in Babies?

Reflux is very common in young babies due to the immaturity of their lower oesophageal sphincter (LES), the muscle that acts as a valve to keep stomach contents from flowing back up into the oesophagus. This condition is often exacerbated by several factors:

The limited size of a baby's stomach means it can easily become overfull.
Large or rapid feeds can put additional pressure on the lower oesophageal sphincter.
Swallowed air during feedings can also exacerbate reflux by increasing pressure in the stomach.
Tight nappies or clothing can add pressure on the baby's abdomen, making reflux more likely.
Environmental tobacco smoke may also contribute to reflux in babies by relaxing the sphincter (LES).
A liquid diet and the tendency for babies to lie flat after feeding make it easier for reflux to occur.

Fortunately, reflux usually improves over time as babies grow, begin eating solids, spend more time upright, and develop stronger stomach muscles.

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Causes of Reflux in babies — This illustration explains the common causes of reflux in babies.

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Recognising Symptoms of reflux in Babies

Understanding the difference between normal physiological reflux (GOR) and reflux disease (GORD) is crucial for identifying and managing symptoms effectively.

Symptoms of Gastro-Oesophageal Reflux (GOR):

Vomiting: Your baby might vomit milk or food, usually after feeds, though it can occur at any time. Vomiting tends to be more frequent if the baby is laid down flat soon after a feed or handled excessively. The vomiting can sometimes be quite forceful, and the amount may seem large, but this is not necessarily an indicator of severity.
Behaviour: Most babies with reflux are otherwise well, exhibit no signs of distress, and continue to gain weight and breathe comfortably.
Additional Signs: The baby may occasionally cough, splutter, grimace due to the acidic taste, and then swallow the regurgitated milk again. Hiccups are more common in babies with reflux but are generally harmless.

Symptoms of Gastro-Oesophageal Reflux Disease (GORD):

Gastro-oesophageal reflux disease (GORD), on the other hand, is characterised by frequent vomiting along with additional symptoms such as:

Irritability: This is characterised by irritable and unsettled behaviour, particularly during or after feeds due to acid irritation in the lower oesophagus. The distress often worsens toward the end of a feed or immediately after. While most babies are calm and content after feeding, a baby with GORD may become particularly unsettled during this time.
Back Arching: Arching of the back can occur during or after feeds.
Sleep Issues: Difficulty sleeping due to acid reflux is common.
Feeding Issues: The baby may refuse to feed, starting off feeding well but then stopping and becoming unsettled. This may include turning their head, arching their back, and crying, which can limit the duration of feeds and lead to shorter, more frequent feeding sessions.
Weight Concerns: Poor weight gain or weight loss.
Respiratory Issues: Choking, coughing, or wheezing during or after feeds may occur.

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How Is Reflux Diagnosed?

Reflux is typically diagnosed by a healthcare provider through the baby’s history and examination. For gastro-oesophageal reflux disease (GORD), a more detailed assessment by a paediatrician or paediatric gastroenterologist is often required. In rare cases, additional tests may be recommended, such as:

pH Probe Test: A thin tube is inserted through the nose into the oesophagus to measure acid levels over 24 hours. This test helps assess the frequency and severity of acid reflux.
Upper Gastrointestinal (GI) Series: X-rays are taken after the baby drinks a contrast liquid, allowing detailed imaging of the oesophagus and stomach. This test can help identify structural issues or severe reflux.
Endoscopy: A flexible tube with a camera is inserted into the oesophagus to visually inspect the lining and take tissue samples if necessary. This test is usually reserved for more severe or persistent cases.

For practical reasons, a healthcare provider may recommend a trial of treatment, such as adjustments in feeding or medication, to see if symptoms improve. This trial can also help in confirming the diagnosis.

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How Are Reflux and GORD Treated?

Most babies with reflux don’t need any special treatment. Reflux is a natural process that usually improves as your baby grows. If your baby is spitting up but is otherwise happy and gaining weight, they are likely a “Happy Vomiter,” meaning it’s more of a messy inconvenience than a medical issue.

However, if your baby appears uncomfortable or shows symptoms of GORD (Gastro-Oesophageal Reflux Disease), treatment options can help manage their discomfort. Here’s what you can do:

1. Feeding Adjustments

Maintain Current Feeding Method: Continue breastfeeding or using your chosen formula. Don't switch unless your doctor, child health nurse, or lactation consultant advises you to do so.
Upright Positioning During Feeds: Hold your baby in an upright position while feeding. This can help reduce reflux by using gravity to keep milk in the stomach.
Regular Burping: Burp your baby frequently during and after feeds. This helps release air bubbles in the stomach, thus decreasing the pressure. Lower stomach pressure can reduce the likelihood of milk being pushed back up.
Smaller, More Frequent Feeds: Try offering smaller amounts of milk more frequently. This can reduce reflux, but make sure the total amount of milk volume in a 24-hour period stays the same. Keep in mind that some hungry babies might get frustrated with smaller feeds.
Paced Bottle Feeding: Paced feeding is a way of bottle feeding that allows your baby to control the flow of milk better. This method aims to slow down feedings to closely mimic breastfeeding. By holding the bottle horizontally, just enough to fill the teat with milk, the flow is slowed, requiring the baby to work harder to obtain the milk, similar to breastfeeding [6]. This approach allows the baby to take natural breaks during feeding, reducing the risk of overfeeding and subsequently decreasing discomfort and reflux.
Thickened Feeds: Your healthcare provider might suggest thickening feeds to help reduce vomiting. For formula-fed babies, this can be achieved by using a special thickener like Aptamil Feed Thickener or by switching to a pre-thickened 'AR' or 'Reflux' formula. For breastfed babies, a thickener can be added to expressed breast milk or administered as a gel during or after breastfeeding. Although thickened feeds may cause constipation in some infants, they are generally well tolerated.

Note: When using a thickener or AR formula, a faster flow teat or a variable flow teat is usually recommended.

Antacid Trial: Some healthcare providers might recommend a short trial of Sodium Alginate (Gaviscon Infant), which forms a protective barrier on top of stomach contents to prevent acid reflux into the oesophagus. It's important to only use this under medical supervision for babies under 1 year old, and it should never be used with thickened feeds or AR formula due to the risk of bowel obstruction.

Remember, always consult with your healthcare provider before making significant changes to your baby's feeding routine.

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2. Positional Changes

Upright Positioning After Feeds: Keep your baby upright during and for 20-30 minutes after feeds. This can help reduce reflux by using gravity to keep stomach contents down.
Avoid Over-Stimulation: Try not to bounce your baby or provide too much stimulation after feeding.
Tummy Time and Left-Side Lying: These positions might help with reflux symptoms when your baby is awake and supervised [1,2]. Never use these positions for sleep due to the increased risk of SIDS [2,4,5].
Safe Sleeping Position: Always place babies on their back to sleep on a firm, flat mattress. Most studies have found that elevating the head of the bed does not reduce reflux symptoms and might be dangerous [4,5].

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3. Other Measures

Avoid tight nappies: Looser nappies can reduce pressure on your baby's tummy, which may help reduce reflux.
Smoke-free environment: Studies show that exposure to environmental tobacco smoke contributes to reflux in babies [3].

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4. Medication

Medication is used to treat gastro-oesophageal reflux disease (GORD) rather than simple reflux. Some babies require medication to help manage their symptoms when other measures aren't sufficient.

Acid-Suppressing Medications: For severe cases of GORD, your doctor may prescribe medications like Omeprazole (Losec) or Esomeprazole (Nexium) to reduce stomach acid and alleviate symptoms.

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Important Considerations: These medications should only be used under medical supervision, are not the first line of treatment, and may have side effects. Regular attempts to wean off should be made under medical guidance.

Note: Acid suppression medications reduce the pain associated with acid reflux but do not reduce the amount of vomiting. Vomiting will typically improve as the reflux naturally resolves over time.

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5. Surgical Intervention (Rare)

In extremely rare cases, when all other treatments fail and the baby is severely affected by GORD, a surgical procedure called fundoplication may be considered. This surgery tightens the valve between the stomach and the oesophagus to prevent reflux.

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Remember, every baby is different. What works for one might not work for another. If you're worried about your baby's reflux, always talk to your health care provider for personalised advice.

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When To Seek Help?

While reflux is common in many infants, certain symptoms and situations may indicate gastro-oesophageal reflux disease (GORD) or another condition and warrant medical advice. Seek help if you notice any of the following:

Poor weight gain or weight loss
Refusal to feed or feeding difficulties
Unsettled and irritable behaviour, especially during or after feeds
Choking, coughing, or wheezing during or after feeds
Breathing difficulties or turning blue (cyanosis)
Presence of blood or bile (green or yellow) in vomit
Blood or mucus in stool
Consistently spitting up forcefully (projectile vomiting)
Swollen or tender abdomen
Fever
Spitting up begins at age 6 months or older
Spitting up persists after 18 months of age

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Will My Baby Grow Out of Reflux?

The good news is that most babies grow out of reflux by the time they are 12 months old. As babies grow, their digestive systems mature, and they spend more time upright, reducing the frequency of reflux episodes. In the meantime, following the tips mentioned earlier can help manage symptoms and keep your baby comfortable.

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Summary:

Gastro-oesophageal reflux (GOR) is a common condition in infants where food or milk from the stomach flows back into the oesophagus or mouth. This is particularly frequent in young babies and typically resolves by the time they reach one year of age.

Generally, reflux is harmless and doesn't require treatment. However, if your baby appears uncomfortable or shows symptoms of Gastro-Oesophageal Reflux Disease (GORD), they may benefit from measures such as feeding adjustments or positional changes. If these measures are ineffective, treatment options may include medications, and in rare cases, surgery. While reflux often improves naturally over time, it's advisable to consult a medical professional if you have concerns about your baby's well-being.

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Frequently Asked Questions:

My baby is vomiting a lot – could it be something else besides reflux?

While reflux is a very common cause of vomiting in babies, persistent or severe vomiting could indicate gastro-oesophageal reflux disease (GORD) or other conditions. If you notice any red flags (as detailed above), it’s important to consult your doctor to explore other potential causes. These may include viral illnesses, urinary tract infections, food allergies, or surgical issues such as pyloric stenosis (a condition where the pylorus, the muscle valve between the stomach and small intestine, thickens and obstructs food passage).

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If my baby has reflux, could it be a milk allergy?

Severe reflux, feeding difficulties, and extreme irritability in some infants may be linked to a milk allergy. The most common allergies are to cow's milk protein and soy. If you suspect a milk allergy, consult your child and family health nurse, GP, or paediatrician for guidance on appropriate breastfeeding practices and formula options that may help.

For more information about milk allergies, you can read further here: Milk Allergy in Babies: What Every Parent Should Know

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Could reflux be the cause of my baby's colic?

Colic is characterized by excessive crying in infants with no apparent reason, typically starting in the second week of life and peaking around 6 weeks. It often worsens in the afternoons and evenings. While colic and reflux disease share some symptoms, such as fussiness and discomfort, reflux disease is usually marked by recurrent regurgitation and may cause distress both day and night, especially during or after feeds. If your baby is crying excessively or you have concerns about their well-being, consult your maternal and child health nurse, GP, or paediatrician.

You can read more about colic here: Coping with Colic and Purple Crying: Tips and Strategies for Parents

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Does my child have silent reflux?

The term "silent reflux" is often used to describe an unsettled baby who does not vomit or posset but shows signs of discomfort. However, this term is controversial and not a recognized medical diagnosis, as there is no scientific evidence to support it. These symptoms might instead be related to colic or other issues. For management strategies and support, consult your child and family health nurse, GP, or paediatrician.

You can also read more about settling strategies here: Coping with Colic and Purple Crying: Tips and Strategies for Parents

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Should my reflux baby sleep on their back? Will they choke if they spit up?

All babies should be placed to sleep on their back, even babies with reflux. This position does NOT increase the risk of choking. It is, indeed, safe.

The American Academy of Pediatrics 2022 guidelines wrote this: “The supine (lying on the back) sleep position on a flat, non-inclined surface does not increase the risk of choking and aspiration in infants and is recommended for every sleep, even for infants with gastroesophageal reflux. The infant airway anatomy and protective mechanisms protect against aspiration” [4].

Similar advice is given by Red Nose Australia- the national authority on safe sleeping practices for infants and children [5].

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Should I elevate the head of the cot? Do crib wedges help reflux?

Elevating the head of a baby’s cot is not recommended for reducing reflux symptoms. Most studies have found that this practice is not effective and can increase risks, such as the baby rolling to a position that may cause breathing problems or increase the risk of sudden infant death syndrome (SIDS) [4]. Similarly, crib wedges and other products designed to elevate the cot are neither safe nor effective for managing reflux. Red Nose Australia, the national authority on safe sleeping practices for infants and children, also advises against the use of such products [5].

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Should I Introduce Solid Food Earlier?

There is currently little evidence to suggest that introducing solid foods early will help with reflux. It’s important to follow the Australian Infant Feeding Guidelines, which recommend starting solids around six months of age, and not before four months.

When your baby is ready, begin introducing a variety of solid foods while continuing to breastfeed or formula feed. Initially, the introduction of solids is more about allowing your baby to explore different smells, tastes, and textures rather than increasing their food intake. Your baby will still get most of their nutrition from milk during the first few weeks of introducing solids.

Once your baby is ready and not before four months, you could trial rice cereal or pureed foods such as sweet potato, carrots, avocado, bananas, and pears, which may help reduce reflux symptoms in some babies. However, be cautious with acidic fruits (like tomatoes and oranges), as they can worsen reflux.

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Written by Dr Samuel Heitner

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Click HERE to book a consultation with Dr Sam.

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References

The following references provide additional information and support for the guidelines discussed in this article:

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