Is It Colic, Infant Reflux or GERD? Learn How to Tell The Difference
It can sometimes be difficult for a parent to understand whether the baby has colic or reflux (and even GERD) since some of the symptoms (eg. poor sleep, constant crying) can be similar. It's also extremely important to rule out reflux as a cause of this crying, as it's becoming widely acknowledged that many cases of colic are actually undiagnosed and untreated cases of reflux. In these cases, simply treating the reflux may eliminate the colicky behavior.
The easiest way to determine whether a baby has colic or reflux is to look at the definitions and symptoms of each. Then compare them to your child's symptoms.
Colic can be defined as uncontrollable, extended crying in babies who are otherwise healthy and well-fed. All babies cry, but when they cry for more than three hours a day, three to four days a week, they are said to have colic.
■ Symptoms of Colic
The main symptom is continuous crying for long periods of time. This crying can occur at any time of day but it usually gets worse at night. It's not believed that colic is caused by pain although a colicky baby may look uncomfortable or appear to be in pain. They may lift their head, draw their legs up to their abdomen, pass gas and become red-faced. Poor sleep habits are also common.
The term reflux is a shorter way of referring to GER (Gastro Esophageal Reflux) and is simply defined as the backward flow of stomach contents up the esophagus. GER is a physiological process that happens to everyone—young and old—from time to time, particularly after meals and many times we are not even aware it is happening. In babies it generally occurs from immaturity of the LES (Lower Esophageal Sphincter) which is the muscle between the stomach and esophagus.
Some common symptoms of uncomplicated reflux can include:
· constant or sudden crying or colic like symptoms
· irritability and pain
· poor sleep habits typically with frequent waking
· arching their necks and back during or after eating spitting- up or vomiting
· wet burp or frequent hiccups
· frequent ear infections or sinus congestion
Your child does not need to exhibit all of these symptoms, in fact, only having one of the above could mean they have reflux. It does not; however, mean they need treatment. If your child is showing one or more of the above symptoms but is otherwise happy and healthy then some simple lifestyle modifications will likely make life better until they outgrow it.
In contrast, GER (Gastro Esophageal Reflux) is referred to as GERD (Gastro Esophageal Reflux Disease) when complications arise. GERD is a pathological process and the complications can be typical (failure to thrive, feeding and oral aversions, esophagitis, etc) or atypical (wheezing, pneumonia, chronic sinusitis, etc). Patients with GERD have complications arising from their GER that necessitate medical intervention. GERD is also referred to as "Pathogenic GER". It is estimated that approximately one in three hundred children will present symptoms of GERD and is more common in children with neurological impairments.
Symptoms indicative of Reflux Disease or GERD:
· refusing food or accepting only a few bites despite being hungry or the exact opposite requiring constant
· small meals or liquid
· food/oral aversions
· excessive drooling
· running nose, sinus infections
· swallowing problems, gagging, choking
· chronic hoarse voice
· frequent red, sore throat without infection present
· chronic ear infections
· respiratory problems—pneumonia, bronchitis, wheezing, asthma, night-time cough, aspiration
· gagging themselves with their fingers or fist (sign of esophagitis)
· poor weight gain, weight loss, failure to thrive
· erosion of dental enamel
· neck arching (Sandifer's Syndrome)
· bad breath
Basically, if your baby is spitting or throwing up, or his/her fussiest, most irritable times are during or after a feeding, it's reflux not just colic. But remember to watch the other symptoms carefully because not all babies with reflux will spit up, this is referred to as silent reflux. Further, if your baby is experiencing any health problems that require medical intervention, it's not just colic or reflux, it's likely GERD.
Infant Reflux - Non-Prescriptive Natural Remedies
Babies are being medicated for infant reflux at an alarming rate these days, often before common sense lifestyle changes are recommended. As a society we have been programmed to look for medication as a quick symptom mask but when it comes to a baby we are more concerned that the product is "natural".
There has been a huge increase in the last decade of "natural remedies" for infant reflux and colic in the form of gas drops and gripe water, Baby's Bliss and Colic Calm to name a few. Be aware that any product can use the term natural and not all ingredients are required to be listed on the packaging. These products may be no more natural than pharmaceuticals, and in fact some have been subject to recent market recalls. Read our article on the differences between probiotics, gripe water and simethicone drops for more information.
Oral treatments, whether natural or medicinal, may be beneficial for easing immediate symptoms but we believe in eliminating the actual cause of the problem. Many things can cause a baby intestinal discomfort, or trigger fussiness, colic or infant reflux.
Before introducing a foreign substance into your baby's already delicate system try these natural remedies for infant reflux. In cases of severe GERD the baby may need a combination of oral treatment and these natural remedies.
Because colic and fussiness are frequently caused by undiagnosed and often silent infant reflux (meaning the baby refluxes but does not spit up), these home remedies may also be helpful for easing colic and fussiness.
Infant Reflux - Breastfeeding Natural Remedies
● Breastfeed your baby
● Minimize forceful letdowns.
● Be sure to finish the first breast before switching sides.
● Nurse on one breast for at least 2 hours before switching if your baby wants to constantly nurse.
● Alter your diet for a trial period of several weeks.
● Avoid offering your baby formula as a means to end fussy behavior.
Infant Reflux - General Feeding Natural Remedies
● Breast or bottle feed your baby on an angle of at least 30 degrees and with a totally straight spine. Give your baby smaller, more frequent feedings that are easier for him to digest.
● Burp your baby thoroughly.
● Exercise extreme caution if you choose to thicken feedings.
● Experiment with different bottles if bottle feeding.
● Keep your baby upright for 20-30 minutes after each feeding.
● Keep from stimulating your baby for 20-30 minutes after each feeding.
● If your baby is having a feeding aversion or seems to be more uncomfortable than usual check with your pediatrician to be sure that the medication dose he is on is still appropriate for his weight.
Infant Reflux - Positioning as a Natural Remedy
● Avoid placing your baby flat on his back.
● Avoid putting your baby in any seat or baby carrier (bouncy or car or sling) that causes him to slump right after feedings.
● Elevate the head of the crib and changing station by 30 degrees.
Infant Reflux - Other Natural Remedies
● Change your baby's diaper before feeding.
● Avoid putting your baby in tight diapers and clothing that put pressure on his tummy.
● Avoid exposing your baby to cigarette smoke, dust, mold or other respiratory triggers.
● Carry or hold your baby often with a straight spine and no pressure on his tummy.
● Don't neglect yourself.
Infant reflux natural remedy #1: Breastfeed your baby.
Breastmilk digests much quickerthan artificial milk formulations. The less time food spends in your baby’s tummy, the lower the chances of spit-ups. In addition, the motion your baby’s tongue makes while breastfeeding creates waves along his GI tract that help push food lower in his stomach and into the intestines.
Infant reflux natural remedy #2: Minimize forceful letdowns.
Your baby may have difficulty keeping up with the flow and swallow too much air, which can cause gassiness and more spitups. Try pumping a small amount first, or removing your baby until the spray has lessened.
Infant reflux natural remedy #3: Be sure to finish the first breast before switching sides.
Leave your baby on the first breast as long as he appears to be sucking for comfort rather than calories. Only offer him the second breast when he truly begins to seem hungry.
Infant reflux natural remedy #4: Nurse on one breast for at least 2 hours before switching if your baby wants to constantly nurse.
This will help keep your baby from overeating.
Infant reflux natural remedy #5: Alter your diet for a trial period of several weeks.
Dairy, spicy or acidic foods, caffeine and alcohol can all trigger infant reflux through your milk supply. You may also consider an elimination diet.
Infant reflux natural remedy #6: Avoid offering your baby formula as a means to end fussy behavior.
Infant reflux natural remedy #7: Feed your baby on an angle of at least 30 degrees and make sure he has a totally straight spine.
The more upright he is while feeding, the more milk will enter the intestines and the less will come back up. A baby lying on his back or with even a slightly "kinked" or turned neck will swallow more air and is more likely to reflux.
Positioning during feeds is an important natural remedy for infant reflux.
Infant reflux natural remedy #8: Give your baby smaller, more frequent feedings that are easier for him to digest.
A too-full tummy can put pressure on the lower esophagus sphincter, causing your baby to spit up. Your baby may want to eat more often to compensate for this.
Infant reflux natural remedy #9: Burp your baby thoroughly.
If breastfeeding, you may want to try burping between breasts, anytime your baby pulls off your nipple, or anytime he gets squirmy. Bottle fed babies should be burped frequently, even as often a every 1-2 ounces if they seem irritable or gassy after a feed.
Choose burping positions that put less pressure on baby’s tummy. Place his head over your shoulder and hold him in close to you so he doesn’t slump or slouch, gently patting his back. Try gentle bouncing on a therapy ball, walking up and down stairs while patting his back, or raising on toes and thumping down on heels rhythmically. The key is to find what works for you and do it as frequently as possible. You may also consider purchasing some clothing protection.
Infant reflux natural remedy #10: Exercise caution if you choose to thicken feedings.
Many pediatricians and websites will suggest that you thicken liquid feeds (including breastmilk) with cereal. Thickening breastmilk is ineffective because the digestive enzymes in breastmilk will thin cereal out within minutes. Thickening feeds can be beneficial for some babies but can actually be detrimental for others. If you do decide to thicken feeds, keep a journal of what times you are thickening Baby’s liquids and note any possible reactions he may have. Reactions can occur instantaneously or up to 16 hours later.
Infant reflux natural remedy #11: Experiment with different bottles if bottle feeding.
Every baby has a different suck and may do better with a different nipple. Because of this there is no best nipple for all babies with infant reflux. However, Dr. Browns' bottles do actually reduce the amount of air your baby takes in because of it's internal straw system that removes the vacuum that builds up inside the bottle. Try Dr. Brown's bottles to see if they reduce your baby's gas and infant reflux.
Infant reflux natural remedy #12: Keep your baby upright for 20 – 30 minutes after each feeding.
Let gravity help keep food down. Be sure that baby is upright with a straight spine, and not just upright but slumped.
Infant reflux natural remedy #13: Keep from stimulating your baby for 20-30 minutes after each feeding.
Stimulation, including laughing and crying, can trigger infant reflux episodes. If he is stimulated, swaddling is a great way to soothe and calm him.
Infant reflux natural remedy #14: If your baby is having a feeding aversion or seems to be more uncomfortable than usual
Check with your pediatrician to be sure that the infant reflux medication dose he is on is still appropriate for his weight. Colds and teething are also common causes for nursing strikes and feeding aversions. Try a feeding wedge, co-sleeping, increased skin-to-skin time, bathing together, nursing in a quiet and dim room with no distractions, or nursing necklaces.
Infant reflux natural remedy #15: Avoid placing your baby flat on his back.
Studies have shown that infant reflux is minimized by left side lying and prone (stomach) positioning. Please discuss prone positioning with your doctor before trying as it is thought to be a contributor to SIDS.
Infant reflux natural remedy #16: Avoid putting your baby in any seat or baby carrier (bouncy or car or sling) that causes him to slump right after feedings.
This often puts pressure on his stomach and can cause infant reflux. In the bouncy seat, a rolled up hand towel behind your baby may stop him from slumping as much.
Infant reflux natural remedy #17: Elevate the head of the crib by 30 degrees.
You can purchase infant reflux wedges for sleeping or try using old phone books to prop up the crib.
Infant reflux natural remedy #18: Elevate the changing station and change your baby's diaper before feeding instead of after.
When changing your baby's diaper, roll him side to side when placing the diaper under him rather than bringing his legs up toward his head which can squish the tummy.
Infant reflux natural remedy #19: Avoid putting your baby in tight diapers and clothing that put pressure on his tummy.
Infant reflux natural remedy #20: Avoid exposing your baby to cigarette smoke, dust, mold or other respiratory triggers.
Anything that can trigger breathing difficulty can also trigger infant reflux
Infant reflux natural remedy #21: Carry or hold your baby often.
Carried babies are less stimulated and so experience fewer incidences of colic and infant reflux. Never put your baby on your hip! This puts pressure on his tummy. The best position that I found to carry my son was with his bottom on one forearm and my other hand behind his back to support it and keep him close to me. Carriers and slings are a particularly nice way to hold your baby and still get things done. Be careful that your sling or carrier keeps your baby's spine completely straight and does not put pressure on his tummy.
Infant reflux natural remedy #22: Don’t neglect yourself.
Dealing with a fussy baby is sometimes overwhelming. You may be experiencing sleep deprivation, self-doubt, some degree of depression and general frustration at not being able to soothe your infant reflux baby.
14 steps to reducing your infant's Reflux
RMacLean March 2005
It's important to realize that not all babies with reflux will require medication or have difficulties with their reflux. Many infants, usually called happy spitters, will benefit greatly from some simple steps that you can start trying right now. Many of the things listed below will help with your baby's discomfort and spitting up, eliminating the need for medication.
If, after trying all the below listed tips, your baby is still spitting up, or having difficulties with their reflux, read about whether or not medication may be needed and what medications will likely be used.
■ POSITIONING STEPS for reducing infant reflux
1. Positioning During and After Feeds
Keeping the child upright during and for at least thirty minutes after feeds can help to reduce reflux by allowing gravity to work at holding the food in their tummies. As well, after feeding, try to keep them as motionless as possible for at least thirty minutes after feeding. Formula fed babies may require longer periods since formula is digested slower than breastmilk.
2. A Word About Car Seats
Some car seats position baby in such a way that they hunched and slouched over, putting added pressure on their tummies which can increase reflux episodes. 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.
3. Sleeping Position
As with positioning after feeding, keeping baby propped during sleep is essential when they have reflux. It can help reduce painful reflux episodes and reduce the risk of aspiration. For more info on propping baby, see the article on propping.
4. Prone vs. Supine (Front vs Back)
The American Academy of Pediatrics recommends all babies sleep in the supine position (on their backs) because it has been shown to reduce the risk of SIDS. This is fine for babies with reflux as long as the baby is safely propped up to at least 30%, we found the higher baby is propped the better. Having said that, many babies with reflux prefer sleeping in the prone position (stomach), also elevated of course, and may have less reflux episodes in this position. Discuss this with your doctor and he can help decide if it's okay, and how to safely manage allowing baby to sleep in the prone position. It's very important to discuss this with the doctor before trying it as babies with reflux are already at an increased risk of SIDS.
Try carrying baby around as much as possible in a baby carrier through out the day. Carried babies tend to cry less and crying will make reflux worse, plus, it keeps baby upright.
■ CLOTHING and reflux
6. Avoid Tight Clothing
Tight clothing, particularly clothing that's tight around baby's tummy, can make reflux worse by increasing pressure on the LES (lower esophageal sphincter). Make sure baby stays in loose fitting, elastic waists whenever possible.
FOOD / FEEDING tips and suggestions
Breastfeeding is definitely best for a baby with reflux because it is more hypoallergenic than formula and is digested twice as fast as formula. If breastfeeding is not chosen or not possible by the mother, formula changes can help some babies. If the baby has a milk or lactose allergy or intolerance giving the baby formula that is milk based can make reflux worse. Read about the different types of formula available and discuss this possibility with your pediatrician.
Some babies with reflux will respond well to thickening their feeds with cereal. Thickening formula can help for a few reasons. The added weight of the cereal in the food helps to keep the food from splashing around in the baby's belly and can help keep it down. Babies who are having difficulty gaining weight may also benefit from the added calories. Generally, it's recommended that about one tablespoon of cereal should be added for every ounce of formula. If the formula isn't thick enough, it won't work. Also, some babies may react poorly to rice cereal which is generally the first tried, so adding oatmeal instead may work better for some babies. As always discuss this with your pediatrician before trying it.
9. Feeding Time
When and how much a baby is fed can also have an impact on their reflux. Smaller more frequent meals through out the day work much better than larger, less frequent meals. Also, avoid feeding baby right before bedtime, particularly if the baby is already a poor sleeper.
If you are breastfeeding, try eliminating the foods that can make reflux worse. Dairy products are a big offender, as is caffeine, fatty foods, spicy foods, citrus fruits. If eliminating these things seems to help, you can slowly (about one thing a week) start to introduce one thing at a time back into your diet and watch baby's reactions. This will help give you an idea of exactly what was making the reflux worse, so that you (hopefully) don't need to give up everything you love, just one or two things.
Stopping to burp baby frequently (at least after every ounce) during feedings can help.
12. Provide a Pacifier
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.
13. Infant Massage
Try infant massage, it's been shown to improve digestion and will help relax baby.
14. Avoid Certain Foods and Liquids
More so for older children and babies, there are certain foods that are known to make reflux worse. If you breastfeeding, as mentioned above avoid these foods in your own diet. The complete list, as put forth by PAGER is below:
Vegetables (due to high acid or belching)
* Green Peppers
* Brussel Sprouts
* Tomato Juice
Fruits (due to high acid or lots of fiber and seeds)
* Apple (especially peels)
* Bananas (can cause constipation)
* Citrus fruits
* Milk (lactose intolerance can provoke reflux in some people)
* Coffee (even decaffeinated)
* Carbonated Beverages
* Caffeinated Beverages
* Beans (gas producing)
* Oats (rolled oats OK)
* Tofu (avoid large quantities)
* Barley ( OK if perled barley is cooked 10-15 min)
* Fatty or Fried Foods (fats take longer to digest)
* Meat with connective tissue/gristle (take longer to digest)
* Chili Powder
* Peppermint/Spearmint (Wintergreen is unrelated)
* Foods with "air" such as fluffy baked goods, Meringues.
* Swallowing air by sucking on hard candies or drinking from straws
* Rye Seeds
* Meat Extracts
* Black Pepper (White pepper is OK)
* Creamy Foods/Gravies (High fat content)
* Gooey Pastries (High fat content)
* Simple Sugar Foods
* Excessive Fiber (increase very gradually as tolerated)
* High Energy Foods (digest slowly)
* MCT Oil (medium chain triglycerides, digest slowly)
* Guargum (thickener, digests slowly)
Reviewed By Dave Olson, MD
Fellow, American Academy of Pediatrics
Graduate University of Michigan School of Medicine
Gastroesophageal reflux (GERD)
Reviewed by the BabyCenter Medical Advisory Board
Last updated: December 2007
Is it normal for my baby to spit up so much?
What causes GERD?
How serious is it?
What can I do to ease my baby's suffering?
Should I take my baby to the doctor if I think she has reflux?
What will the doctor do?
How is GERD diagnosed?
■ Is it normal for my baby to spit up so much?
That depends. It's perfectly normal for babies to spit up after feedings, or even to vomit once in a while, without apparent cause or warning. Frequent vomiting or spitting up is called gastroesophageal reflux (or just reflux), and most babies outgrow it.
Your baby might have other symptoms along with spitting up or vomiting that could mean she has gastroesophageal reflux disease, or GERD. For instance, she might show signs of abdominal pain, like arching her back, drawing up her legs, and waking screaming from her sleep, or she's coughing or gagging during feedings.
If your baby vomits forcefully after feedings, schedule a doctor's appointment. This is called projectile vomiting, and it's just what it sounds like — she's spewing. Projectile vomiting is a sign of pyloric stenosis, a condition that can lead to serious problems like malnourishment and dehydration.
■ What causes GERD?
All babies are getting used to the process of eating and digesting, but some have more trouble nailing it than others — and so have more spitting up and vomiting than others. If your baby has GERD, it's probably because her esophageal sphincter (the valve connecting the esophagus to the stomach) is weak or not working properly yet. This allows food and gastric juices to flow back up out of her stomach and into her mouth.
■ How serious is it?
Most babies with reflux grow out of it in their first year, as the sphincter muscle gets stronger. But that doesn't mean you should take reflux lightly.
If your baby has GERD, it's important to monitor her weight. Some babies with GERD don't gain properly because they simply aren't keeping enough food down. Others lose their appetite because all that stomach acid pushing up into the esophagus (called heartburn in adults) can hurt the throat and, in severe cases, make it hard to swallow.
If some of her stomach contents enter her nose and lungs, a baby with GERD might develop respiratory problems like pneumonia, a cough at night, and sinus and ear infections. The stomach acid can also damage tooth enamel. GERD can make your early days together very difficult, as you struggle to comfort, feed, and clean your baby up.
■ What can I do to ease my baby's suffering?
Try holding her in a more vertical position while feeding, and keep her upright for a bit right after feedings, too. (Don't put her down for tummy time right after she eats, for example.)
Giving her less breast milk or formula at each feeding (if you can get away with it) may help, too. You can make up for the smaller quantity with more frequent feedings.
If your baby is formula-fed, you might also try adding a little rice cereal to the bottle or using a formula that comes with "added rice." (First ask your baby's doctor whether you should try this and how to mix in the cereal.)
These suggestions aren't guaranteed to soothe your baby — they may even make her crankier — but they're worth a try.
■ Should I take my baby to the doctor if I think she has reflux?
If your baby spits up quite a bit but doesn't seem uncomfortable and is gaining weight just fine, then you probably don't need to. If you're concerned, by all means mention it at her next checkup.
On the other hand, if your baby has more serious symptoms — especially if you think the reflux is distressing her and affecting her weight gain — schedule an appointment as soon as you can. Your baby's doctor can tell you whether she has GERD and help you ease her suffering.
■ What will the doctor do?
For starters, he may prescribe medication. Some babies respond right away to antacids or acid blockers, and that's the end of the problem. Most infants can tolerate children's antacids and low doses of acid suppressors (but never give these to your baby without consulting a doctor).
Ideally your baby won't have to take these medications for more than a month or so before the reflux tapers off.
Drugs that work to keep things moving downward in the digestive tract are also available. If your baby has the signature symptoms of GERD, her doctor should be able to find the treatment that best settles the uprisings without side effects.
■ How is GERD diagnosed?
Your baby's doctor may be able to diagnose GERD simply by examining your baby and listening to you describe her symptoms. If he's in doubt, or if your baby has been unable to find relief by taking the drugs described above, the doctor might do further tests or refer you to a gastroenterologist to be sure that GERD is the problem.
These tests may include X-rays of the area (this is called an upper GI series). For damage to show up on an X-ray, your baby needs to drink a chalky substance called barium beforehand.
The doctor might also do a scope of the digestive tract, complete with biopsies (small tissue samples) and something called the 24-hour PH-probe study, in which a very thin tube is threaded through the nose down to the base of a baby's esophagus and monitored for 24 hours. No, it's not a lot of fun for your baby (or you), but it will provide lots of helpful information for figuring out what's ailing your baby.
* What is reflux?
* Should I be worried about my baby?
* What causes reflux?
* When spitting up is normal!
* Symptoms of GER - physiological reflux
* When reflux is a serious problem!
* Symptoms of GERD - pathological reflux
* How long does reflux last?
* When spitting up is NOT due to gastro-esophageal reflux
* What you can do to help
* What tests are available?
* What treatments are available?
* When to see your doctor
■ What is reflux?
Gastro-esophageal reflux occurs when stomach contents are brought back up into the esophagus (food pipe), throat or mouth.
Infant reflux, gastric reflux, acid reflux, silent reflux, GER (gastro-esophageal reflux), GERD (gastro-esophageal reflux disease) and heartburn are all names that are commonly used to describe this condition.
■ Should I be worried about my baby?
Parents oftent worry unnecessarily when their healthy, thriving baby spits up (possets). For the majority of babies spitting up is not a condition that requires treatment, rather it is a phenomenon (a natural happening) that requires understanding.
Spitting up is classified under two different categories...
1. GER (gastro-esophageal reflux), due to physiological reasons i.e. normal bodily functions.
2. GERD (gastro-esophageal reflux disease), due to pathological reasons i.e. abnormal bodily functions OR disease.
It is estimated that approximately 50% of all healthy, thriving babies have 'reflux' and will spit up occasionally or regularly during the early months. 100% of all healthy babies will occasionally bring up milk into their throat and reswallow it; this is commonly referred to as 'silent reflux'. For babies, this believed to be a physiological response to protect against overfeeding.
Unlike adults, refluxing for babies is a normal body function and is rarely associated with 'heartburn'. Breastmilk (with a pH acid balance of 7.2) or infant formula (with a pH of 6.9) dilute the concentration of acid in a baby's stomach, so that when spitting up occurs there is no irritation of the esophagus (heartburn) and therefore no pain.
It is estimated that between 1 to 3% of babies experience problems associated with GERD (due to abnormal bodily functions or disease). GERD can affect babies in 3 different ways.
1. Esophagitis (heartburn) can occur if a baby refluxes so frequently at times when there is little milk content in the stomach, thereby bringing up stomach acid which has the potential to cause heartburn (inflammation of the food pipe). Untreated heartburn causes the baby extreme distress, day and night. Feeding difficulties are common due to the pain associated with swallowing.
2. Poor growth: The baby may struggle to gain weight or loose weight due to an inability to keep down sufficient quantities of milk to sustain healthy growth; or due to a feeding aversion associated with the pain of heartburn.
3. Respiratory problems can develop as a result of refluxed stomach contents entering the lungs. When respiratory problems are evident it is often difficult for medicos to determine if refluxing caused the respiratory problem or whether the coughing associated with the respiratory problem triggers the refluxing.
Unfortunately, the time when GER (i.e. spitting up due to normal infant body functions) in a healthy, thriving babies is most common, coincides with a time when approx 1/3 of all babies experience prolonged periods of irritability i.e. 2-16 weeks. This can be very confusing for parents and health professionals alike and as a result GER is often mistakenly diagnosed and treated as GERD.
What you should know!
* Irritability and sleep disturbances in healthy, thriving babies are most often due to reasons unrelated to reflux.
* Gastro-esophageal reflux does not make your baby immune to other problems suspected of causing infant colic. It's important not to dismiss other possibilities as the reason for distress simply because your baby happens to spits up (or not).
* The incidence of reflux is significantly increased, for suseptible babies, when overfeeding occurs. (See Hungry Baby for common reasons why overfeeding occurs.)
* Refluxing occurs day and night, therefore 'heartburn' is not confined to one particular time of the day.
* GER will not respond to medications, because as a normal body function it does not require 'treatment'.
* Antacids medications will not decrease a baby's irritability where irritability is due to reasons unrelated to heartburn.
* Inappropriate use of antacid medications may prove harmful because stomach acid aids healthy digestion. The long term effects of giving infants antacid medications has not been fully studied.
■ What causes reflux?
There is a ring of muscle (valve) at the top of the stomach which opens to allow fluid and food to enter the stomach, the valve then closes. In babies this valve frequently relaxes and opens at the wrong time and this allows milk and/or food to flow back up the esophagus, and possibly out of the mouth*.
Along with this lax valve, babies have a tendency to reflux because...
1. Babies have small stomachs.
2. Babies spend a lot of their time in a lying position.
3. Babies are fed mostly a fluid diet. (Milk can easily come up, particularly with a burp.)
4. Handling, such as diaper changing and bouncing can increase the pressure on a baby's full tummy, which then increases the risk of spitting up.
*Spitting up, possetting, spilling, throwing up, chucking up, vomiting, regurgitation, rumination and re-swallowing are some of the many words used to describe when milk is brought back up.
■ When spitting up is normal!
There is a wide range of different behaviors that can be described as normal when it comes to GER, due to physiological reasons. (Remember these babies are gaining good amounts of weight).
Your baby may spit up a tiny amount occasionally or he may throw up large amounts on a regular basis. Sometimes the milk may simply spill out of his mouth or at times the flow can be forceful and may even come out of his nose. Spitting up can occur shortly following a feed or anytime, even hours later (even while he's sleeping).
Your baby may reflux without spitting up, as small amounts of milk can rise up into his throat without coming out of his mouth. You can sometimes tell that this is happening because he might make swallowing noises. This is referred to as 'silent reflux'
Although, this condition is often called 'acid reflux', spitting up (or regurgitation) rarely causes heartburn, because frequent milk feeds dilute the concentration of acid in a baby's stomach. Most babies, particularly those who spit up milk, experience no pain and they continue to gain good amounts of weight despite the frequent spills. (However, they may be distressed for other reasons).
Some babies will squirm or cry and look uncomfortable, presumably because of the sour taste of the milk once it has been mixed with stomach acid and not necessarily because of a burning effect of heartburn. When this happens your baby may cry for a few minutes, in which case he may only require a little comforting until it passes. OR...
Your healthy, thriving baby may cry for hours and be irritable most of the day. In this situation he may (or may not) benefit from the use of thickened formula and/or antacid medications, see your baby's doctor for advice on medications. Where medications fail to relieve the distress of your healthy, thriving baby it is very likely that reflux is not the cause of your baby's distress and you may need to look for other reasons.
In deciding whether your baby requires treatment or not depends on whether reflux is causing him discomfort or if it is affecting his growth. Provided he's healthy and gaining enough weight, then reflux requires no treatment other than a few minor changes in feeding management and handling that may help to reduce the incidence.
■ Symptoms of GER - physiological reflux
* Spitting up can vary from a little to a lot*.
* Spitting up may be seldom or regular.
* Your baby calms quickly following spit ups.
* Your baby gains enough weight, possibly LARGE amounts of weight, as increased spitting up is frequently linked with over-feeding. (See Hungry baby for more on over-feeding.)
Irritability, sleeplessness and wakefulness are most likely to be due to other reasons. (See Crying baby and Infant colic.)
*Often the amount of milk brought up is far less than it looks. Even 1 oz can look like a huge amount when it comes from a small baby.
■ When reflux is a serious problem!
Only a tiny percentage of babies experience serious problems related to GERD, due to pathological reasons (i.e. abnormal body functions or disease), as opposed to a large percentage of healthy babies who experience GER, due to physiological reasons (normal infant body functions) who may also happen to be irritable and wakeful for other reasons.
Your baby may throw up such large amounts OR throw up so often that he fails to gain weight OR loses weight. Your baby may reflux so forcefully that milk shoots many feet across the room. Milk may be brought up in one huge vomit or he could vomit in continuous waves.
Your baby may experience extreme discomfort due to burning effects of heartburn, caused by prolonged and repeated refluxing of stomach acid (which causes irritation and inflammation of the esophagus). Babies may develop blood stained vomiting and occasionally difficulty swallowing. Esophagitis may cause your baby to scream inconsolably for hours. (Unlike infant colic where crying is often worse in the evening, the screaming related to esophagitis occurs multiple times during the day and night.) Feeding problems commonly develop because of this discomfort and this often affects the amount of weight gained. (Feeding problems also occur for many reasons unrelated to reflux.)
Although rare a baby may experience respiratory problems from stomach contents refluxing and entering the windpipe and lungs. Sometimes it is only while investigating the cause of recurrent breath problems such as wheezing, coughing or pneumonia that reflux is diagnosed.
If your baby is NOT gaining enough weight, screams for hours day and night, or if he has other symptoms such as vomiting blood or breathing problems, he needs a full medical assessment by a doctor and/or pediatrician.
■ Symptoms of GERD - pathological reflux
Before a diagnosis of GERD can be made a number of the following symptoms or behaviors would need to be evident.
* The amount of milk spit up may be small or it may large and projectile (shoot out).
* Some babies re-swallow (and not spit up) stomach contents which has been brought up into their throat or mouth.
* Feeding problems such as screaming during feeding and/or refusing to feed are commonly associated with GERD (however GERD is not the only reason for feeding difficulties to occur).
* Distress from heartburn/esophagitis is more likely if refluxing occurs at a time when there is little milk left in the stomach i.e. 1.5 to 2 hours after feeding.
* Extreme distress (as opposed to fussiness or irritability) and prolonged inconsolable screaming (as opposed to consolable crying) occur frequently during the day and night. Rarely is this distress confined to one particular time of day.
* Sleep disturbances: Short daytime naps and frequent awakenings overnight where your baby is unable to be comforted quickly. (There are also many reasons for disrupted sleep patterns that have nothing to do with GERD).
* Blood in vomit (can be red or dark coffee color).
* Repeated coughing or wheezing.
* Repeated chest infections.
* Breathing problems.
* Failure to gain weight OR weight loss.
Back arching is commonly considered to be a sign of GERD. However, for infants younger than 3 months back arching is a sign of distress. Babies will also behave this way for reasons unrelated to pain or discomfort of GERD and therefore it is not a reliable sign of GERD.
■ How long does reflux last?
Reflux gradually improves with time as a baby's digestive system matures. For most babies spitting up has decreased remarkably by the age of 6 or 7 months and disappears completely by the age of 12 months. In severe cases it may persist for up to 18 months.
The amount and frequency of spitting up usually decreases once a baby is able to sit independently and/or once solid foods are introduced into his diet. For some babies, the amount of spitting up may increase again when they being creeping (crawling), due to once again spending time in a horizontal position, however this generally improves once the skill of walking is mastered.
■ When spitting up is NOT due to gastro-esophageal reflux
Spitting up can be due to a food or milk allergy or intolerance so it's important to observe for other symptoms as well. Additional gastric symptoms to watch for include...
* Abdominal bloating.
* Excessive gas.
* Diarrhea (frequent, watery bowel motions)*
* Failure to gain weight OR loss of weight.
* Diaper rash.
*Frequent watery bowel movements are very normal for healthy thriving breastfed infants and NOT necessarily a sign of a food or milk allergy or intolerance.
There are ALSO a number of other RARE conditions that can result in spitting up. Almost ALL of these can be easily ruled out by the simple fact that a baby is gaining healthy amounts of weight. A child that is failing to gain enough weight requires a thorough medical assessment.
■ What you can do to help
If your baby is otherwise healthy and thriving and experiences no (or minimal) discomfort as a result of reflux, he doesn't need any special treatment. However, you may find using some of the following strategies helpful to reduce the amount of spitting up.
1. Change diapers before feeding and not after, on a full tummy.
2. Feed your baby in a semi-upright position.
3. Slow down the feed (see How long to feed a bottle fed baby).
4. Avoid overfeeding (see Hungry baby for reasons why babies overfeed).
5. Burp your baby frequently during feeding (see Burping your baby).
6. Hold your baby in an upright position for 15 or 20 minutes following a feed; in a semi reclining position and not slumped forward (which will increase pressure on his full tummy).
7. Try thickened milk feeds (see Infant formula for details on thickening formula).
8. Avoid fruit juice or acidic fruits (see Carbohydrate malabsorption).
9. Discuss sleeping your baby on his tummy with your pediatrician. Although sleeping on the back is recommended in order to reduce the risk of SIDS, babies with severe GERD benefit from sleeping on their tummy. Only do this under doctor's orders.
Although commonly recommended, recent studies suggest elevating the head of the crib offers no significant benefit.
Although solid foods may prove helpful to decrease the amount of spitting up, early introduction of solids (babies less than 6 months) should not be used as a first line management, unless advised to do by your doctor. Solids can cause or complicate any feeding problems. Starting solids too soon can increase the risk of developing allergies.
PLEASE NOTE: Weaning a baby from breastfeeding to formula feeding does not improve this condition.
■ What tests are available?
Most babies with reflux will not require any diagnostic tests. A medical diagnosis is often made solely on the parent's description of their baby's behaviour. The condition is confirmed when symptoms improve following a successful a trial of medication.
If medications prove unsuccessful in a child who fails to gain sufficient weight, further investigation may be necessary. Test may include...
An acid sensitive probe is passed through the nose into the esophagus places in the child's esophagus. This measures the frequency and duration or reflux episodes by measuring the pH (acid) level of a 24-hour period. The information is collected electronically and analyzed by a computer.
The baby swallows a liquid containing barium, which shows up under X-ray. The liquid outlines the esophagus and stomach showing any narrowing.
Results from a barium swallow are not always accurate, because reflux does not occur all the time. Nor is it necessarily helpful for a healthy, thriving baby. Although a barium swallow may confirm a baby is refluxing, it does not identify if the baby is experiencing heartburn (esophagitis).
The main purpose of a barium swallow is to exclude other structural abnormalities that might cause vomiting. It is generally reserved for situations where a refluxing baby is loosing weight despite adequate milk intake.
Esophageal pressure testing (Manometry)
This measures how the muscles of the esophagus are squeezing.
This is where a tube, which contains a small camera, is places into the child's esophagus, so that the doctor can see any signs of inflammation in the esophagus. It requires either sedation or a full anesthetic and is rarely performed on infants due to the invasive nature.
See University of Virginia Health System article for further details on the limitations of diagnositic tests.
■ What treatments are available?
The most common medical treatment for reflux is the use of antacid medications. These are used to reduce the effects of heartburn. Although many antacids can be purchased 'over-the-counter' most are not suitable for babies. An inappropriate use of antacids may be harmful.
There are also medications that can be used to speed up the movement of stomach contents into the intestines (in doing so reducing the amount of reflux). The benefits of these medications need to be weighed against the risk of possible side effects. Your doctor will be able to advise you on the appropriate us of reflux medications for your baby.
In extreme cases, where a baby regularly throws up huge amounts and fails to gain weight OR suffers from esophagitis (inflammation of the esophagus) as a result of severe heartburn, surgery may be necessary.
■ When to see your doctor
Contact your baby's doctor should any unusual symptoms appear such as...
* If your baby's vomit is green or blood stained.
* If your baby frequent projectile vomiting.
* If your baby fails to gain enough weight.
* If your baby has other physical symptoms.
Written by Rowena Bennett
RN, RM, RPN, CHN, Grad Dip Health Promotion.
Added Nov 2003. Reviewed April 2004.