I Think My Baby Has Reflux…Now What?
As a pediatrician, one of the most common questions that comes up in the first year of life is about reflux. It’s a confusing topic for parents because, on the one hand, don’t all babies ‘spit up’? So, what makes it reflux? And what makes reflux a problem? And, wait a minute, vomiting is different from reflux??
Phew. Let’s take a deep breath, go back to the start and figure out what reflux actually is, what to do about it (if anything) and when to call your pediatrician vs. just grab an extra spit up cloth.
What is infant reflux?
Gastroesophageal (gastro= stomach, esophagus = tube from mouth to the stomach) reflux (GER) is a common and normal process in children whatever their age. It is defined as passage of contents from the stomach into the esophagus, with or without regurgitation or vomiting. So, this means it is totally normal, and in fact expected, that reflux will occur in children multiple times per day.
There is a sphincter, a ring-shaped muscle that opens and closes, at the bottom of the esophagus. The younger a child is, the less effective this sphincter is. Kids are just more floppy in general, so this makes sense! Children and especially babies will therefore be more likely to have episodes of reflux. Premature babies tend to have a lot of reflux as their sphincter is even less well-developed. Reflux is also more common in babies because they spend most of their time lying flat or nearly flat, meaning they don’t have the help of gravity keeping any of their stomach contents down.
Is infant reflux the same as spitting up?
Yes! GER is just the medical term for spitting up, and is a completely normal and expected occurrence in infants less than a year old. It peaks at around 4 months, and steadily decreases from then, becoming very uncommon after 1 year old. The milestone of sitting unsupported is often a big turning point as to when reflux begins to improve because...gravity!!
Normal spitting up is effortless and tends to be worse after a feeding, although it can occur at any time (just lay them flat for a nap and they spit up all over themselves? Yup, been there).
When is baby reflux a problem?
Problem reflux is given the name ‘Gastroesophageal Reflux Disease’ (GERD). It is defined as when spitting up “produces troublesome symptom(s) and/or complication(s)”. Nice and vague, right?
It is important to note that as parents, we don’t even know about most episodes of reflux, because the spit up doesn’t make its way to (and out of) the mouth. For those episodes that do, usually we’re the ones with the complications, with the complication being that we now need to find a clean shirt.
With babies, it can be so hard to figure out why they are upset- hungry, tired, too hot/cold, reflux….just because?? How do we know that it is reflux-related?
Infants with gastroesophageal reflux who feed and thrive well and have no other symptoms; they are described as ‘happy spitters’. However, here are some signs that indicate reflux may a problem in your little one:
Episodes of extreme distress (excessive crying, hard to calm down) with or without spitting up
Refusing feeds or seems to have a poor appetite
Gagging
Poor weight gain
Poor sleep
Chronic cough and/or wheezing
Episodes of back arching, rigid posture, usually after feeds
For the most part, GERD is diagnosed clinically (i.e. just based on symptoms and a physical exam by your pediatrician and/or gastroenterologist). Specialized testing, such as monitoring the pH of the esophagus with a flexible probe or an endoscopy (a camera which goes down the esophagus and can take a biopsy) may be needed, and these tests would be at the discretion of a Pediatric Gastroenterologist.
Is there any treatment for baby reflux?
We want to do anything we can to help our babies, and make them comfortable. Seeing them spit up, especially if it causes distress, is no fun for anyone!
With kids, we never like to prescribe a medication unless we absolutely have to, so below are some first steps to minimize reflux and any associated distress.
Thicken the feeds: usually using infant cereal. Oat cereal is preferred over rice due to the concerns over heavy metal levels in rice cereal. Often one teaspoon per ounce of milk is recommended. Thickened formulas are available too. Discuss with your pediatrician before thickening your baby’s feeds.
Keep them upright: keeping them in an upright position for 20-30min after a feed will reduce reflux. But remember, infants should always be placed flat on their back for sleeping.
Lifestyle changes: slower flow nipples (if bottle-feeding) can give more time for the milk to enter the stomach and settle.
Cow’s milk elimination: if the above does not help, a trial of a ‘predigested’ formula such as Alimentum where the proteins are already broken down may be recommended in formula-fed infants. If breast-fed, elimination of cow’s milk from Mom’s diet can be tried. But, it can take several weeks to see any changes with this, and elimination of other allergens from Mom’s diet is sometimes recommended which can be very challenging and restrictive. Again, these changes should first be discussed with your pediatrician.
Medication is only considered if the above are not effective. It must always be remembered that this condition gets better with time, so any medication that is started should be regularly re-assessed so that it is used for the shortest time period possible.
The medications prescribed for GERD work by reducing the amount of acid the stomach makes. Then, when stomach contents come back up as reflux, they are less acidic and, hopefully, less uncomfortable. The medications DO NOT reduce the frequency or volume of spitting up. So, keep those burp cloths handy!
Like all medicines, they have side effects. In addition, our gastric acid is what helps kill bacteria and limits intestinal and respiratory infections. The potential risks and benefits merit a thorough discussion with your doctor before starting any of these types of medications.
What is the difference between infant reflux and baby vomiting?
Vomiting is when the contents come out of the mouth forcefully, often shooting out inches from the mouth rather than dribbling out. Sometimes spitting up can be confused with vomiting especially if accompanied by burping (which tends to project the spit up a little bit) but this still does not qualify as forceful, no matter how voluminous the spit up is.
Here are the main reasons to call your doctor when it comes to vomiting:
Repeated episodes of vomiting
Concern for dehydration or unable to keep down fluids
Vomit is green (think lime/highlighter green)
Vomit has blood in it
Diarrhea is also present
Your little one looks sick OR
You are worried!
Remember, you know your baby better than anyone. Anytime you are worried, or something just doesn’t seem ‘right’ listen to that feeling and act on it! And make sure to keep burp clothes in every room of your house for at least the first 6 months after you bring your little one home because more likely than not you’ll at least have some ‘happy spitting’ episodes in your household.
Joana Fraser, MD is a pediatrician and founder of Littlemore, a women-owned and led company making the snacks you always wished existed for your kids. She lives in Massachusetts with her husband, 2 boys and cavalier king charles spaniel.
