Having a baby is exhausting for anyone. But there’s a whole separate level of exhaustion and desperation that comes with caring for a baby who is crying nonstop, spitting up, not gaining weight, and seems to be in pain when you feed them. In other words, a baby with reflux.
And of course, everyone has advice — but much of that advice is confusing, contradictory, and not based in evidence.
Having had three babies with reflux myself, and having taken care of countless more as a pediatrician, I want to tell any parent who is in the reflux trenches the following:
- This is a tough hand to be dealt. If you’re struggling, know you’re not alone. Getting support for yourself is probably one of the most important ways to help your baby.
- Part of the reason there is so much confusion and limited information out there is because we’re not yet at a stage where the available research provides a satisfactory answer. Babies cry for many reasons, and teasing apart those reasons is frustrating. It’s very unlikely to be related to something you are doing “wrong.”
- The most effective treatment for infant reflux, by far, is time. While there are things that sometimes help, they don’t always work. But I can promise you: it gets better, and you’re not failing your child.
Now let’s break down the information we do have about reflux — what it is, what you can do, and red flags to look out for. If you have further questions, hopefully this can help you have a more informed conversation with your own pediatrician.
What is reflux?
Gastroesophageal reflux (GER) is when stomach contents flow backward into the esophagus. To some extent, it is physiologically normal in babies: some studies suggest it is seen in about half of all babies under 3 months. It also may get worse around 4 months before it begins to improve. This is because the band of muscle separating the esophagus and stomach — which is designed to limit backwashing — is underdeveloped and loosens intermittently and randomly in babies. So any changes in position, expansion of the stomach, or pressure on the abdomen will more easily push stomach contents in the wrong direction. Think of it like squeezing a loose-lidded plastic bottle in the middle.
Babies also spend a lot of time lying flat, which means they don’t have any help from gravity to help things move in the “right” direction.
Reflux symptoms usually begin in the first 3 months of life, sometimes worsen around 4 months, and then gradually improve; most infants have outgrown physiologic reflux by the age of 1 year. If symptoms begin after 6 months, there may be something more going on.
How is GER different from GERD?
Some kids handle reflux smoothly. They are what we call “happy spitters.” They may spit up curdled milk during or after feeds, or even hours later, but the hallmark of this type of gastroesophageal reflux is that they are otherwise unbothered, they do not cry or fuss with feeds, and they gain weight well.
Other babies, however, struggle. The backflow of stomach acid and partially digested milk can lead to heartburn, pain with feeding, chronic cough, nasal congestion, decreased weight gain, and/or feeding aversion. These babies have what is called gastroesophageal reflux disease, or GERD. They may develop extreme fussiness, crying with feeding, and back arching (called Sandifer syndrome).
Most, but not all, will spit up. Silent reflux is when the stomach contents rise enough to irritate the esophageal lining without actually coming out of the mouth. Parents of babies with silent reflux often feel overlooked because their concerns are sometimes dismissed, but regurgitation is not always present in cases of GERD.
What can you do at home if you’re worried about reflux?
Most pediatricians and parents are comfortable trying non-pharmacologic, conservative measures for reflux as a first step — which is appropriate.
Some strategies that can help include:
- Smaller, more frequent feeds
- Change the feeding position and try feeding the baby upright
- Hold your baby upright (or baby wear) for 20 to 30 minutes after each feed
Although burping can be helpful for some babies, it is not essential — and in other babies, it can increase the rate of spitting up. It’s a relatively harmless intervention, so it’s worth a try, but I would not stress out about this.
Some limited evidence also suggests that supplementation with probiotics can be helpful, and is likely low-risk if you choose high-quality, third-party-reviewed products. The best data we have is for Lactobacillus reuteri, specifically, which has been shown to improve crying time and the frequency of spitting up in at least one study (with the caveat that any symptomatic improvements are based on self-report). Probiotics are a hot topic of research, but creating robust randomized controlled trials can be very challenging in this population. Always talk to your pediatrician before starting any medication or supplement.
What other treatment options are there for reflux?
If conservative measures do not help, next steps can include thickening feeds or adjusting the baby’s diet. It is best to try these steps under the guidance of your pediatrician.
I’m also frequently asked about elimination diets and medications, so let’s get into both.
Elimination diets
Elimination diets in breastfeeding moms are a common recommendation online and on social media. There is some evidence that certain types of protein allergies can cause reflux symptoms in babies.
But because maternal nutrition is still a priority, elimination diets should be done methodically, with appropriate nutritional forethought and under the guidance of a health care provider. Of the different allergies, cow’s milk is the most common culprit, so we usually start with a two-week trial where we eliminate cow’s milk proteins before considering eliminating other proteins (such as soy).
If the above conservative measures are not helpful, your pediatrician may recommend a trial of hydrolyzed formula (this means the proteins are broken down and easier for a baby’s digestion).
It may take several days, and up to two weeks, to really see a difference with any of the above measures, which can be especially tough for parents who are dealing with fussy babies.
Medications
Over the years, the threshold for prescribing medications to help with reflux has changed. This is because the evidence that medication actually helps with crying, spitting up, or fussiness is mixed. While some studies show improvement with the use of medications, others do not show much of a difference when compared with placebo or other lifestyle changes.
Additionally, there are side effects to consider. In adults, long-term use of the medication class proton pump inhibitors has been associated with infection, nutritional deficiencies, fracture risk, and more, and in general, acid suppression long-term is not ideal. The data in infants is more limited, but at least one study has shown an increased risk of respiratory and other infections in infants and children who have taken these medications.
The most frequently used acid-reducing medications fall into two major categories: histamine-2 receptor antagonists (such as ranitidine, cimetidine, and famotidine) and proton pump inhibitors (such as omeprazole, lansoprazole, and pantoprazole). There are also other types of medications that are less commonly used. Although symptom control between the two categories of acid-reducing medication is comparable in infants, studies in adults show that PPIs are superior. For this reason, most clinicians will trial a PPI first.
The most important thing to know if you start medications is that there is value in making a plan to reassess need periodically. Because GERD symptoms naturally improve over time, we recommend trying medication for four to eight weeks and then reassessing whether to continue.
As with any intervention, part of the decision to move forward means weighing pros and cons. For a baby who is truly miserable, not gaining weight, and for whom none of the conservative measures have worked, medications may be the right choice.
To sum up your treatment options:
- Start with lifestyle and environmental changes, which are low-risk and can be quite helpful: feeding smaller volumes, changing feeding positions, and holding the baby upright after feeds.
- Probiotics may be helpful as well.
- If these interventions don’t help and a baby remains symptomatic, the next steps include changes in diet and considering medication, although these help in only a subset of babies.
- If you do go with medication, go with the lowest dose for only as long as it is needed. Make sure you have a plan with your physician to reassess the need for medication within four to eight weeks.
One thing to avoid
The internet is rife with anecdotes and advice about how to help reflux babies. Rest assured, if there was any consistent intervention that we knew was effective and safe, pediatricians would be shouting it from the rooftops.
One common concern from parents is that putting a baby flat on their back might increase their risk of choking or aspiration from spit-up, so many parents will consider elevating the head of the crib or using sleep positioners and wedge pillows. Please: do not put your baby on an incline or have them sleep in a car seat or swing.
Let me reassure you: babies have inbuilt mechanisms that help protect their airways. There is no evidence that sleeping flat on the back increases the risk of choking in babies with reflux or that elevating the head significantly improves reflux symptoms meaningfully enough to outweigh the risks. On the other hand, there is ample data that the best and safest sleep position for an infant is flat on their back.
What are the red flags?
If you see any of the following, be sure to reach out to your pediatrician immediately.
- Vomiting that contains blood or bile (is green)
- Forceful vomiting
- Sudden vomiting developing after 6 months
- Abdominal distention or pain
- Poor weight gain
- Recurrent pneumonia or concern for aspiration
- Blood and/or significant mucus in the stool
The bottom line
- Spitting up on its own does not necessarily mean there is a problem. At least half of babies spit up early in life. Spitting up may get worse before it gets better, often peaking around 4 months.
- If a baby has other concerning symptoms for reflux (poor weight gain, feeding aversion, crying with feeding, back arching, extreme fussiness), they may have GERD. The trouble is that some of these symptoms can also be signs of other conditions, such as colic or cow’s milk protein intolerance. Even in these cases, the overwhelming likelihood is that the babies will outgrow their symptoms, but they can cause a lot of distress — for the baby and for the parents.
- We do not have consistent interventions that help every baby with GERD, so the best approach in a baby who is symptomatic is methodical.
- Having a baby with reflux can be draining. Make sure you have support systems in place, and reach out to your own health care provider if you feel too overwhelmed. Postpartum support is crucial here!
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A PPI medication was a game changer for us! Our kiddo went from under the 1st percentile for the first 3 months, started PPI, to 50th percentile at 8 months.