Baby Reflux: What It Is and How To Treat It

When your baby spits up regularly, it creates a ton of extra laundry. And more importantly, it can be concerning! The volume of spit-up always appears so large. You may worry whether they’re losing too much of their feeds and if it will affect their weight gain. Spit-up often looks alarming, but reflux in babies is almost always common and normal. So, what exactly is reflux, and when is it concerning? What might be causing your baby’s frequent spit-up? What signs or symptoms should you look for to know if infant reflux might be something more serious, and does your baby need treatment? This article will cover all those concerns and more!

Reflux in babies is when the contents of an infant’s stomach come back up into the esophagus, or the tube connecting the mouth to the stomach. This reflux most often happens just after eating and can happen multiple times throughout the day and night.¹ Sometimes, the contents come all the way back up into the mouth, called regurgitation. If regurgitation happens forcefully with significant discomfort, it’s called vomiting.² If reflux in babies causes symptoms that affect their health or quality of life, or if it causes tissue damage in their esophagus, it’s called gastroesophageal reflux disease, or GERD.^1,2

Several factors may contribute to reflux in babies. Some of the main ones include having an immature digestive system, overfeeding, and milk protein intolerance:

A sphincter is the muscle between the esophagus and the stomach that keeps the stomach “closed” so it doesn’t overflow. This esophageal sphincter in babies can be weak. The pressure in the stomach is higher than the pressure in the lower esophagus. So, the stomach contents are pushed upward through the weak sphincter.¹

If your baby takes in too much milk or sucks it down too fast, their small stomach may not be able to handle it. Having a stomach completely full of milk can cause forceful spitting up. This can happen in babies fed formula through a bottle, but it can also happen in breastfed babies, especially when the mom has an oversupply of milk or a fast letdown.^3,4 While milk does help neutralize acid reflux so that it doesn’t cause painful heartburn, too much milk can worsen reflux.^5,11

Sometimes, an intolerance to cow’s milk can cause acid reflux in babies. This isn’t a true allergy, although sometimes it’s referred to as a “infant milk allergy.” ¹² Cow’s milk can be in most infant formulas or in a mother’s breastmilk if she consumes dairy. However, spitting up would likely not be the only symptom of this type of allergic reaction. If your baby has cow’s milk intolerance, you might also notice abdominal pain and blood or mucus in the stool. So, usually, a doctor wouldn’t recommend eliminating cow’s milk or changing infant formulas just for spit-up.⁶

If your baby has symptoms of cow’s milk protein allergy, your doctor may recommend eliminating it from their diet. You should see improvement in allergic symptoms within two to four weeks.¹

Reflux in babies is very common. Around 3 in every 4 babies experience regurgitation in their first two months of life. Most of the time, it resolves on its own by the time babies turn 1.¹

Reflux sometimes shows no signs at all — we all reflux throughout the day and may not even know it. This is sometimes called silent reflux in a baby. For other babies, the only sign or symptom of reflux is a bit of spit-up without discomfort. These babies are often called “happy spitters.”¹

In more severe cases, signs of gastroesophageal reflux disease (or GERD) in babies may include:

• Coughing, gagging, or choking during feeds: When reflux in babies becomes severe, the regurgitated contents of the stomach may become aspirated into the lungs, causing respiratory symptoms.¹
• Irritability: The burning of the stomach acid in the esophagus can cause pain and extreme sensitivity in a baby with reflux.¹
• Back arching: A baby arching their back is how they may position themselves to help alleviate the sensation of heartburn.¹
• Food or milk refusal: Once an infant learns that eating will cause them pain, they may start refusing feeds to avoid discomfort.²
• Poor weight gain: If a baby starts refusing feeds and loses calories through spit-up and vomiting, they may stop gaining adequate weight.²

If your child’s symptoms match the signs of reflux disease above, this is typically enough to diagnose gastroesophageal reflux disease in babies. Often, no additional tests are necessary.² However, if there’s a question about what’s causing your baby’s reflux symptoms or if there’s concern about their severity, additional tests to diagnose GERD may be performed:

In some infants, milk protein allergy can cause reflux as a symptom. Milk protein allergy affects 3-5% of infants. To diagnose milk protein allergy, your doctor may recommend an exclusion diet in which you eliminate milk protein from your baby’s diet and see if their symptoms improve after three to four weeks. If you’re breastfeeding, this may mean removing dairy from your own diet because milk protein can pass through breast milk. If you’re formula feeding, this may mean trialing a hypoallergenic formula.²

In the hospital, a thin tube can be passed through your baby’s nose or mouth into their stomach then pulled back into their esophagus. It remains in place for 24 hours and measures the acidity of the esophagus to monitor how much and how often stomach acid is regurgitated into the esophagus. This can help to diagnose infant reflux.⁹

If your baby is experiencing forceful or bloody vomiting, poor weight gain, or abdominal pain along with reflux, your doctor may recommend an upper gastrointestinal (GI) series. In an upper GI series, a special X-ray with contrast dye is used to examine the anatomy and function of the esophagus and stomach.^1,7 Your doctor may also recommend endoscopy, in which a camera is inserted into the esophagus to visualize esophageal tissue, or an ultrasound to look for blockage from the stomach into the small intestine, which can also cause infant reflux.⁸

If your little one receives a reflux diagnosis based on symptoms or testing, you might be wondering about interventions and treatments to help. When babies experience reflux without other signs or symptoms such as gagging, bleeding, milk refusal, or breathing difficulties, they may have “functional infant regurgitation,” which requires no treatments.²

Your pediatrician can examine your baby and review their reflux symptoms. Using this information, they can reassure you that their spit-up is normal or recommend lifestyle changes to manage your baby’s reflux, relieve symptoms, and prevent complications.¹ Here are some interventions and treatments for infant reflux that your pediatrician might recommend:

If other children or distractions are around during feeding times, a baby may latch and unlatch frequently to observe their surroundings. If you can, try to retreat to a quiet and calm environment to breast- or bottle-feed. An infant who’s focused on eating will be more attuned to their hunger and fullness cues and more focused on the suck-swallow-breathe pattern necessary for coordinated eating, which can minimize reflux.²

Upright or diagonal positioning during and immediately after a feed can allow gravity to help prevent milk from refluxing back up into the esophagus. Maintain straight body alignment and avoid bending at their hips to prevent applying additional pressure on their stomach. Consider holding them in a slightly upright cradle position or placing them in a swing or bouncer if they’re awake.³

Babies often swallow air during feedings. When it’s forcefully ejected, it can cause vomiting or spitting up of milk alongside the air. Gentle burping your baby by patting your baby’s back halfway through and at the end of each feeding can encourage them to expel air without spitting up.³

Your doctor may recommend adding a small amount of rice cereal to your baby’s milk to thicken their feeds. This reduces spit-ups and can help add calories if your baby is struggling to gain weight due to spitting up. There can be some side effects, and you may need to adjust the volume of your baby’s bottles if you start thickening their milk. So, don’t do this without physician guidance and supervision.²

It’s not typical to recommend medications for the treatment of reflux in babies. However, if your baby’s reflux is causing additional complications such as poor weight gain, refusal to eat, esophageal inflammation, or chronic respiratory symptoms, there are a few medications your doctor may consider for treatment:⁸

• Famotidine: Famotidine (or Pepcid for babies) decreases the acidity of stomach contents, which can decrease the burning sensation in the esophagus. This treatment doesn’t help keep stomach contents down, but it can decrease other reflux symptoms in babies.¹⁰
• Omeprazole: Medications such as Prilosec and Nexium can also decrease the acidity of the stomach to help treat GERD and erosive esophagitis when the stomach contents regurgitate into the esophagus in infants ages 1-12 months.^1,10

All medications have side effects. As always, talk to your child’s doctor before introducing a medication to your baby’s regimen.

If all other interventions fail and your infant continues to suffer from severe reflux that’s causing poor weight gain or respiratory difficulties, doctors sometimes consider surgical intervention. In a procedure called a Nissen fundoplication, the sphincter between the esophagus and the stomach is tightened to reduce the backflow of food from the stomach into the esophagus.^1,8 Needing a surgical procedure is more common in babies with other underlying medical problems.¹³

Most of the time, reflux in babies is mild and resolves without intervention by their first birthday. It causes no known long-term consequences.² Despite the concerning appearance of persistent spit-up, we often consider baby reflux to be normal. As long as your baby is growing well, it’s often best to leave it untreated. You can also try harmless interventions such as minimizing distractions while eating, holding your baby upright, and frequently burping during feeds. Reach out to your pediatrician if you’re concerned about the volume, frequency, or appearance of your baby’s spit-up, and rest assured that they’ll likely grow out of reflux on their own!²