As a breastfeeding mother of an infant with reflux, I know all too well the anxiety of wondering if your child is getting enough milk, gaining enough weight, or if the reflux is hurting their throat. Understanding reflux and what you can do may help calm your worries. Gastroesophageal reflux (GER) is what doctors term “spitting up”. First, it is important to know that spitting up and vomiting are two different things. Vomiting is a forceful expulsion of stomach contents with the contraction of abdominal and chest muscles. Spit up is absent the forceful expulsion or is less projectile in nature.
New parents should be comforted to know that reflux or spitting up is very common. About 50% of infants 0-3 months spit up, by 4 months of age 61% spit up and by 6-7 months only 21% of infants spit up. Most children outgrow reflux; 50% outgrow it by 10 months of age. In most infants, spitting up is natural, due to the short distance between your infant’s mouth and small stomach. Your doctor may refer to your infant as a “happy spitter”. This is an infant who simply spits up frequently but continues to feed well, grow well and is usually not irritable. Infants in this case do not require treatment, but there are a few changes that are recommended if your infant is bothered by his or her symptoms (such as congestion because of spitting up while sleeping) or your quality of life is affected. Reflux medicines are generally not recommended if your infant is a “happy spitter” or does not have injury to the esophagus.
Below are some strategies to dealing with your baby’s reflux.
General Rules to Follow
- Avoid tobacco smoke.
- Keep your infant upright and calm 20-30 minutes after each feed.
- Burp your infant frequently during feedings.
- Continue to place your infant on their back to decrease the risk of SIDS (Sudden Infant Death Syndrome).
- Over feed. Instead, allow your infant to feed on demand and stop feeding once your infant loses interest.
- Place your infant in an infant seat as this can worsen reflux.
Try Milk Free Diet
This includes avoiding casein, whey and beef in mother’s diets for those who are breastfeeding and avoiding formulas with casein or whey for those who are formula fed. Research shows 15-40% of infants with reflux have cow’s milk protein intolerance.
- Continue to breastfeed. Breastfeeding can have a protective effect on spit up in infants.
- Attempt reintroduction of cow’s milk after 1 year of age. The intolerance usually resolves in most infants by then.
- Continue a milk restricted diet if there is no improvement in 2-3 weeks for breastfeeding moms or 1-2 weeks for formula fed babies on a formula without milk proteins.
- Change to soy formula. Infants who are sensitive to milk proteins can also be sensitive to soy proteins.
Try Thickened Feeds
This is not usually recommended as the sole treatment for infants with an injured esophagus. Research shows modest improvement has been seen in frequency and severity of reflux but it does not prevent it.
- Contact your pediatrician or dietitian if you wish to try thickened feeds for your infant.
- Be mindful that mixing in rice cereal can make the milk difficult for the infant to suck out of the bottle and can cause the infant to use more energy to eat which can be problematic if you infant is underweight.
- Be aware that cutting the nipple hole larger can be a dangerous choking hazard if the milk comes out too fast
- Understand that rice cereal mixed in breast milk will often decrease in consistency as time passes due to the enzymes in breast milk breaking it down.
- Stop breastfeeding in order to thicken feeds.
- Use thickening agents in premature infants as these have shown a possible link with necrotizing enterocolitis (a condition that happens when there is serious injury to an infant’s intestines).
My personal experience showed that only burping very frequently (every 5 minutes) and keeping my son upright and calm for 20-30 minutes helped with decreasing the volume of spit up he experienced. At around 8 months his spit up finally resolved. Above all, be mindful that these interventions may not stop reflux in its tracks. You may still have to deal with packing many extra clothes for yourself and your infant, as well as many extra burp clothes until your infant grows out of it. Rest assured that as long as your infant continues to grow well they are probably okay.
When to worry and contact your pediatrician:
- Bloody stools, severe diarrhea, repeated vomiting or vomiting blood.
- Repeated pneumonia.
- Slow weight gain/growth. No weight gain or weight loss.
- Infant crying for > 2 hours.
- Refusal to eat or drink for long period. Pushes nipple out of mouth.
- <3 months and forceful vomiting after each feed but still appears hungry.
- Behavior change: lethargy (tiredness) or decreased responsiveness.
- Arch back during feedings.
Vandenplas Y, Rudolph CD, Di Lorenzo D, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498.
Winter, HS. Gastroesophageal reflux in infants. In: UpToDate, Basow, DS (Ed), UpToDate,
Waltham, MA, 2012.