Reflux in babies - bringing milk up
gastric; reflux; crying; thickeners; antacid; spilling; nutrition; vomiting; formula; gastroesophageal; disease; GORD; GERD; fussy; baby; unsettled; oesophagitis; esophagitis; heartburn; pain; gastro; oesophageal;;
There is a ring of muscle (valve) at the top of the stomach which normally stops what is in the stomach from going back up again. Often in babies this valve does not work very well, so milk and stomach acid can go back up and may spill out of the mouth. This is called reflux.
- Bringing milk (spilling) up is very common for babies, especially after feeds, and is not usually a problem.
- Many babies do not seem distressed (the milk neutralises any acid so that the mixture does not cause any pain for the baby).
- These babies keep enough milk down so that they are not hungry and they grow normally.
- The only 'problem' is that there is a lot of extra washing because the milk brought up may get onto the baby's and the adult's clothing, leaving stains.
- Some babies can have reflux without spilling, but again this is often not a problem.
- Small amounts of the milk and stomach acid go up and down in the tube connecting the throat to the stomach (oesophagus) without coming out of the mouth.
- You can usually tell that this is happening because the baby makes swallowing noises, or sometimes gags.
- Usually milk is the main part of what is brought up and this does not worry the baby, but acid from the stomach may hurt (heartburn) and in bad cases the lining of the tube from the throat to the stomach (the oesophagus) can become sore and inflamed. This is called gastro-oesophageal reflux disease (GORD) and it is actually quite uncommon.
Most babies with reflux do not seem upset by it, but some can be very miserable, and some bring up so much milk that they do not put on much weight.
Note: Urinary reflux - a frequent cause of urine infections - is not discussed in this topic.
Is it gastro-oesophageal reflux disease (GORD)?
Often unsettled babies are said to have GORD (often just called 'reflux'), but GORD may not be the reason for most unsettled behaviour, even in babies who spill. It can be hard to tell whether crying is due to GORD. Some behaviours that might suggest GORD include:
- Spilling or swallowing with signs of being uncomfortable.
- Fussy feeding, when the baby takes a small amount hungrily, then cries and refuses to continue feeding.
- Restless sleeping (for example waking and crying about 20 minutes after being put down to sleep).
- The baby feeling very tense and stiff and arching back (however most babies will become stiff and arch when they are crying hard, and this behaviour is caused by many things, not only reflux).
- Coughing after a feed.
- The baby seems more comfortable if she is held upright.
- The baby seems much better for a short time if she is given an antacid (but only try this if advised to by your doctor).
What you can do
Mild reflux (when your baby is spilling often, but is not distressed).
- Remember that spilling is normal and doesn't need treatment if it doesn't bother your baby.
- Keep your baby upright during and after feeds. Prop your baby on a pillow for nappy changes and floor play.
- Keep your baby quiet for at least 20 minutes after a feed. No bouncing around.
- Research has shown that raising the head of the cot does not help and it may be a sleep safety hazard.
Moderate reflux (when your baby is showing signs of being uncomfortable but is still growing well).
- Try the suggestions listed above for mild reflux.
- For fussy feeders - have a break when your baby becomes fussy, then re-offer the feed after 15 to 30 minutes or so.
- Try shorter feed times if they have been very long and difficult. Babies may do well on less milk than is suggested on the formula can, or on quite short sucking times at the breast - you will need to watch weight gain carefully if you offer less milk.
- Try the usual settling techniques, such as holding the baby in a curved position. (See the topic 'Crying baby'.)
- If feeding problems or crying goes on, the baby needs to be seen by a doctor who can check your baby and advise you what else to try.
Gastro-oesophageal reflux disease (when your baby is very unsettled, not feeding well and not growing well).
- The baby needs to be seen by a doctor and a plan worked out to manage the problem.
- The plan may include ways of thickening feeds, using antacids, or using medicines to reduce the production of acid in the stomach.
- You may also find the suggestions listed for mild and moderate reflux helpful.
- If reflux continues to be a problem the doctor may need to do some tests to find out how best to help your baby.
Living with GORD
- Living with a baby with GORD can be difficult and distressing. You will need a lot of ongoing support.
- Often you are doing everything 'right' but the baby is still unsettled, so you may need encouragement to hang in there until the baby gets a bit older.
- You may feel that the baby doesn't want you if he pulls away when you hold him, and you need to know that he is not doing it on purpose. It is just the way his body reacts to how he feels inside.
Many babies with GORD seem to become more settled when they are able to sit alone (be upright more often) around 6-8 months of age.
If a baby is bottle fed, sometimes thickeners are added to formulas to try to reduce the amount of spilling.
- Formulas are available which already have thickeners added. They are labelled as AR formulas. (AR = 'Anti-reflux'). If you are giving an AR formula, you cannot change the thickness as it is most important that the formula is made up to the right strength.
- Thickeners can also be added to normal formulas, e.g. Gaviscon Infant** (which also acts as an antacid) or Karicare Food thickener**. The advantage of these is that you can vary the amount of thickener to find out what suits your baby best.
- To give a thickened formula you may need to loosen the bottle cap or make a bigger hole in the teat. If this doesn't work you may need to change to a teat with a faster flow.
- With all thickeners, follow the instructions on the can or packet when mixing the formula.
Gaviscon Infant can also be given to breastfed babies, by mixing the powder in a little boiled water and giving to the baby during a feed, for example between sides. This can be difficult.
If your doctor suggests them, thickeners are worth a try, but they do not always help and fussy feeders may be more distressed.
Treatments for GORD
General management ideas as suggested above should be tried before medications are used. It is important to have your baby checked by a doctor to work out what it causing the problem.
The following medications are examples of what may be suggested by the doctor.
- Antacids may help with fussy feeds when given at the time of a feed, or may work best given ½ to 1 hour after the feed when acid levels will be highest. Give as needed rather than regularly, and only keep using it if it really seems to help. If your baby does seen to respond well to it, rather than using antacids for a long time your doctor may suggest a medicine to reduce the amount of stomach acid produced.
- Paracetamol may be useful to relieve discomfort, but if you find you are using it regularly, check with your doctor. Only use it as directed on the bottle.
- Medicines which reduce the amount of acid produced in the stomach may be suggested by your doctor.
If the baby does not get less distressed with 1 to 2 weeks of any medication, its use should be reassessed, which may mean stopping the medication completely rather than increasing the dose. These medications do not help all babies, whether they actually have GORD or not.
If difficulties continue, some investigations can be done to find out more about what is going on. The most usual investigations are a pH probe (to measure acid levels in the lower oesophagus) and endoscopy (to check for oesophagitis (inflammation of the wall of the oesophagus) visually and by biopsy). A light general anaesthetic is required for an endoscopy.
- For support at any time of the day, call the Child and Family Health Service Parent Helpline 1300 364 100
- For an appointment with a Child and Family Health nurse, call 1300 733 606
- Book to download (PDF) - Child and Family Health Service: ‘Settling Your Baby’
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**Any products referred to in our health topics are usually well-known brands readily available in Australia. The brand names are given as examples only, and do not necessarily represent the best products, nor the full range of effective products on the market.
The information on this site should not be used as an alternative to professional care. If you have a particular problem, see a doctor, or ring the Parent Helpline on 1300 364 100 (local call cost from anywhere in South Australia).
This topic may use 'he' and 'she' in turn - please change to suit your child's sex.