Reflux in Infants

Reflux in infants

 

Reflux/spitting up is very common in infants. Normal reflux in babies, also called gastroesophageal reflux (GER), is movement of stomach content up the esophagus (where we swallow) and then either swallowed back down or come out the mouth or nose. There are multiple reasons for reflux as we will discuss below. Reflux in an otherwise growing, happy baby is often not concerning but there are some reasons to be evaluated by a medical provider (see when to follow up with a medical doctor section below). It is also important to stress that no matter how bad the reflux is, the infant (defined as someone who is younger than 12 months old), should continue to be put down on their back to sleep to avoid the risk of SIDS (sudden infant death syndrome); which will also be discussed in more detail below. 

 

Why do babies spit up?

 

Babies have spit up for multiple reasons including

1. That the connection between the esophagus and the stomach (called a sphincter) is not well developed yet. Therefore, there are times that the milk can easily move back up out of the stomach into the esophagus (see picture below) and out the mouth, especially when laying down. When a baby is laying on their back, you may hear a gurgling like sound even without visible spit up since the milk may be coming up but the baby can just swallow it back down. Even if you hear this, sleeping on the back is still the safest position for baby. This is because the esophagus (where you swallow) is furthest back when you lay down so the milk can go just right back to the stomach and no where else. If an abnormal sound is heard, do ensure there is no distress (see reasons to see a medical provider below; the following picture from the Mayo Clinic provides a depiction of reflux in children).
2. Babies are on a liquid diet and that is easier to slide back up compared to thicker foods 
3. Stomachs are still small. So if a baby eats too much, it is more likely to come back up.
   

   Remedies for spitting up

   
   

   If your baby is overall happy around the spit ups, gaining weight, and sleeping well; you do not have worry. They are “happy spitters.” Just more of a laundry issue at that point. But here are some pointers if desire less of a laundry issue or there does seem to be some discomfort or sleeping issues around reflux.

   • Try to hold your baby vertical for a longer period of time (up to 20-30 minutes). This gives the stomach more time to digest the contents and move them out of the stomach before you lay them down (remember, the sphincter is often not yet fully developed so once you lay them down, the food could move right back up due to gravity)
   • Have a break in the middle of the feed to hold your baby upright and burp to allow more time to digest.
   • Slow down the feed. If using a bottle, have it less vertical but not too horizontal that they are swallowing too much air
   • If the baby is at least 4 months old, you can talk to the baby’s provider regarding thickening feeds with oatmeal
   • Try to do smaller feeds since it could be the volume is too big for your baby’s stomach at this time. With smaller feeds, you may have to just feed more frequently. As your baby grows, you can try a higher volume again. 
   • If you are breastfeeding, you can try to make a journal and see if certain foods seem to worsen their reflux. For breastfeeding moms, you can try to eliminate milk, soy and/or eggs but you have to wait 2-4 weeks before knowing if this helped. 
   • If you are using formula, if it has only been a few days, do not switch immediately as it could just take some time to adjust to a new formula. But if it has been a couple weeks and still having issues even though you are following good reflux precautions, you can try another formula which may be gentler for a few weeks.
   • You may have heard about using probiotics, gripe water, or mylicon (baby gas drops).  Talk to your provider before starting these.

   Do NOT veer away from safe sleep practices to help their reflux. Even with reflux, the safest position to put your baby to bed is on their back, without pillows nor blankets and in a flat sleeping area. Therefore, we do NOT recommend elevating one side of the bed or co-sleeping. 

   
   

   Reflux and congestion:

   • Since the reflux can come up to the nose, babies with reflux can seem more congested. The congestion may be from the reflux especially if the congestion worsens after feedings. But if appears to have trouble breathing or any concerns, please see a provider 
   
   

   Reasons to follow up with a medical provider; that it may be more than just normal reflux:

   • Persistent projectile vomiting
   • Green/light green in the spit up
   • Blood in the stools
   • Urine output is decreasing (less than 5 times a day once at least 5 days old)
   • More tired than before
   • Refusal to feed
   • Crying and/or arching the back during feeds (i.e., seems to be in pain)
   • Belly is swollen or distended compared to normal or feels hard
   • Respiratory symptoms—including wheezing and coughing 
   • No longer practicing safe sleep to help their reflux

Mary Meyer, MD, specializes in Pediatrics and Adolescent Medicine at Advanced Pediatrics. Dr. Meyer was born and raised in Northern California. She first ventured to the Washington, D.C. area as a researcher at the National Institutes of Health. Shortly after, Dr. Meyer attended medical school at Loma Linda University in Southern California. She then completed her residency at Inova Children's Hospital in Fairfax, Virginia. Dr. Meyer is board-certified in Pediatric Medicine and her clinical interests include all aspects of pediatric care from newborn to adolescence, and she has a special interest in breastfeeding. Dr. Meyer lives in Northern Virginia with her husband and child. She enjoys board games, hiking, and rock climbing in her spare time.