Infant Reflux

Gastric Reflux (GERD/GORD/reflux or acid reflux) in babies and young children

DISCLAIMER: As a parent of four children with Gastro-Oesophogeal (Gastric) Reflux (as a symptom of an underlying condition) I hope to provide some basic information for families struggling with infants suffering this condition. It should be stressed that I am a parent and despite having considerable experience and knowledge of this condition, I have no medical training and you should always consult your Health Visitor, GP or other healthcare professional if you think your child suffers from Reflux. The information below is a guide only, with links to support sites on the Internet and basic suggestions and information.

WHAT is Reflux? (GORD G Gastro O Oesophageal R Reflux D Disease)

Reflux is when the contents of the stomach are regurgitated from the stomach back up into the oesophagus.  Normally a muscle tightly closes the stomach unless food or drink is being swallowed, or air released. (Burping) This is to stop the back flow of stomach acid and contents but in people with reflux this sphincter muscle does not function normally. It may be weak or relax inappropriately, sometimes due to food intolerances. This can cause heartburn, a symptom caused by stomach acid irritating the oesophagus. If untreated this acid can cause considerable pain and discomfort, in some cases failure to thrive and in the long term other complications are possible. Babies with reflux often cry incessantly, are difficult to soothe and may or may not vomit back feeds frequently. They often scream suddenly, even when asleep.  The emotional stress infant reflux puts on the family can be unbearable.  It's heartbreaking for a parent to not be able to help their distressed baby. If you have an infant with reflux, it can be very hard to find information as most available is tailored to adult reflux and it can be very difficult to get members of the medical profession to accept there is a problem.

Common symptoms of Reflux
  • Irritability and pain, sometimes screaming/crying when asleep. Constant or sudden crying, "colic" like symptoms. Babies can be inconsolable, especially when laid flat.
  • Poor sleep habits, typically with arching their necks and back during feeds.
  • Excessive possetting or vomiting
  • Frequent burping or hiccupping
  • Swallowing problems - gagging, choking
  • Excessive dribbling or running nose
  • Frequent ear infections or sinus congestion
  • Babies are often very windy and extremely difficult to wind or "burp" after feeds, failure to wind successfully usually means reflux and vomiting is worse.
  • Refusing feeds or frequent feeding for comfort
  • Night time coughing, extreme cases of acid reflux can cause apnoea and respiratory problems such as asthma, bronchitis and pneumonia if stomach contents are inhaled.
  • Bad breath, smelling acidy
  • Awful nappies, often rancid/acid smelling and loose. Bowel movements may be very frequent or infrequent with poor motility but not necessarily constipation.

Vomiting feeds


Possetting after a feed is quite normal with most infants. They gain weight, feed well and have no other symptoms, but still this can be upsetting for parents. As the child gets older the lower oesophageal sphincter becomes more competent so the vomiting should begin to show signs of improvement and eventually stop. Some babies suffer more with reflux and about 60% of these babies with persistent reflux may have weight gain issues. It is a very popular misconception though that all babies and children with reflux are underweight. This isn't always the case, some may comfort eat and feed very frequently and not all are sick. Many doctors will tell you babies outgrow reflux once they can sit up, or once they stand. Many do, some will not only fail to outgrow it, but will noticeably worsen with developmental milestones, teething episodes, viral illness and weaning. If you are concerned then always get your child checked by a member of the medical profession.

Silent Reflux

Some babies with reflux do not vomit at all. This is actually more of a problem because the acidic stomach contents go up the throat and back down again, causing twice the pain and twice the damage.

There is no clear relationship between symptoms and the severity of reflux. If your child shows one or more of the above symptoms but is otherwise happy and thriving then some simple lifestyle modifications will probably make life better until they outgrow it - 85% of babies outgrow this condition by 18 months of age, 95% by age 2. (figures correct at times of writing)

Treatment

A GP may offer medication such as Infant Gaviscon. This works in three ways; it thickens the milk making it easier for the baby to cope with, coats the oesophagus all the way down to the stomach and in the stomach it forms a raft over the stomach contents, helping to stop the contents of the stomach from escaping back up the oesophagus. (It can be given when breastfeeding.) Alternatively your child may be referred straight to a paediatrician or gastroenterologist for testing and stronger medication. Surgery is a last resort, where the stomach sphincter is tightened. However this is not without complications and medication and dietary changes are usually tried first, and it is usually only used when the reflux is actually having life threatening implications. Fundoplication usually trades one set of symptoms for another, a useful document about considerations before surgery is here

Addressing potential food allergies (often local gut allergies or delayed hypersensitivities, see here for info on this) such as Cow’s Milk protein can be very helpful, and if you are formula feeding a hypoallergenic formula may be prescribed.

Simple measures to help your child
  • Breastfeeding is definitely best for a baby with simple reflux because it is more hypoallergenic than regular formula and is digested twice as fast as formula. It is also great for reflux due to its natural antacid properties. Feed little and often, on demand. Positioning your baby as upright as possible will help. Many babies with reflux struggle with a forceful letdown, there are excellent tips on coping with this and many other breastfeeding issues on www.kellymom.com/bf/index.html
  • If you are breastfeeding, try eliminating the foods that can make reflux worse but consult your doctor first.  Dairy products are a big offender, as is caffeine, fatty foods, spicy foods, citrus fruits. It is the proteins the baby will be reacting to, and remember there is a 50% crossover between dairy and soya - if your baby reacts to dairy then there is a 50% change they will also react to soya protein.
  • If breastfeeding is not chosen or not possible, formula changes can help some babies.  If the baby has a milk allergy or intolerance giving the baby formula that is milk based can make reflux worse. There is an increasing incidence of gut allergies in both infants and children, there is excellent research to suggest a hydrolised formula can really help a child with reflux. The protein elements are broken down to make them more digestible and less likely to precipitate a reaction.
  • Wind your baby well after each feed, and if necessary between feeds too.
  • Never lay your baby down flat, prop the cot up with books at approx 30 degrees (take care they cannot climb out) and always place something under their heads when nappy changing or dressing.
  • Keeping babies upright whenever possible helps, slings and carriers are a great way to do this, especially traditional type carriers. Baby walkers and gyms put extra pressure on the stomach sphincter and aggravate reflux. Tight clothes do the same so dress your baby in loose clothing.
  • Sucking on a pacifier or dummy, can increase saliva production.  Saliva is alkaline which can help neutralize some of the acid that may come up.
  • Avoid long spells in car seats. Some car seats position babies so they are slouched over, putting added pressure on their tummies.  Look for a car seat that allows baby to be reclined enough that they aren't slouched yet, inclined enough that they are fairly upright.
  • If formula feeding try bottles designed to reduce “colic” symptoms and reduce air intake.

Many doctors increasingly believe that reflux is only a symptom either of immaturity, gut inflammation due to allergies or intolerances, or (rarely) as part of an underlying condition. Trying to understand why your child is refluxing is certainly helpful when offering solid food, but the connection between reflux and gut allergies is pretty high and caution is sensible. 

Thickening feed, reducing feed volume and avoiding known trigger foods can help the symptoms of reflux, but to avoid exacerbating an underlying cause take weaning very slowly. Try one new food at a time, for several days and do not try and rush into another food trial before you are certain your baby is fine with that food. The "Big Four" are best avoided for some time until you can assess how things are going. They are Milk/Dairy, Egg, Soya and Wheat and are the four biggest food allergens.

Skin "reactions" are often just normal rashes so try not to get too hung up on superficial symptoms. It's more important to look for big increases in reflux symptoms and and possible new symptoms like constipation. (Many babies' bowels slow down as solids are introduced so it's really important to keep a level head, you won't be doing your child any favours by recording every slight change and excluding every food you suspect the slightest reaction from.) Our bodies often take time to adapt and there is a lot of good weaning advice on the web, or from health professionals.


Babies with reflux often struggling with mixed consistencies too. They can often feel out of control over feeding and in my experience self feed safe solids more enthusiastically whilst enjoying very smooth and predictable consistency purees from a spoon. My four all enjoyed "suck and dissolve" textures safely but every baby is different. I so support Baby Led Weaning but it should be exactly that - baby led, and a baby with reflux will most likely find a totally free approach stressful and challenging. Persistent reflux can itself cause temporary swallowing difficulties such as delayed swallow and/or pooling of solids as the reflux desensitises the back of the throat, so your baby should be your cue.


My own experience breastfeeding with reflux (twins) is written about on my personal Blog here.

Further information and support
  • Lots of valuable info here http://www.parentsown.co.uk/page/gastro-oesophageal-reflux-disorder-gord
  • Info on Tests and Procedures by parents for parents http://www.parentsown.co.uk/tests_and_procedures
  • Your Health Visitor can offer breastfeeding support or contact the NCT enquiry line 0870 444 8707 to find your nearest breastfeeding counsellor, or La Leche League breastfeeding helpline on 0845 120 2918 .
  • Real sling/carrier advice can be obtained www.thebabywearer.com
  • The Amby baby Hammock is advertised as being helpful for babies with reflux www.ambybaby.com/ although I have never tried one. It can be inclined at 30 degrees.
  • www.kellymom.com is the best site I have ever come across for breastfeeding support and advice.





Copyright Emma-Kate Thompson August 2007 amended 2012

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