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Have you ever eaten Indian food and 20 minutes later you feel a burning in your upper chest and maybe even your throat? [If you’ve ever been pregnant you might have felt this every time you ate.] That sensation is “heartburn.”Heartburn is a symptom of acid reflux, which is when stomach acid makes it back up your esophagus. It’s anything but comfortable. Unfortunately, that is how little babies feel when they have acid reflux.
What causes acid reflux in babies:
Typically, it’s physical. There is a “gate” at the top of everyone’s stomach called a sphincter. In new babies, and especially in premature babies, this gate is underdeveloped. And instead of keeping milk and acid in the belly where it belongs, it allows everything to come right back up.
This is part of the reason why most babies spit up! If their bellies are very full, if they are jostled after a feeding or even if they are burped, milk might come right back out.
However, as we’ll get into, there are things that can exacerbate symptoms.
- The diet of the breastfeeding person
- The constitution of the breastmilk
- The type of formula
- The frequency of feedings
- The size of feedings
Signs of acid reflux in babies:
Parents are often unsure what is a normal amount of spit up. As a Newborn Care Specialist, Postpartum Doula, Lactation Educator and Sleep Consultant, I’ve worked with many babies where the parents were concerned with their baby’s normal amount of spitting. [And I’ve worked with other families where they were told spit-up was normal and didn’t recognize that their baby was suffering from reflux.]
Only a doctor can diagnose your baby with reflux. However, parents and caregivers should know what to look out for.
The most common sign of reflux is spitting up.
What is a normal amount of spit up?
All babies spit up. Usually it’s small amounts. It’s common for babies to spit up directly after a feeding and when burping. The spit up should smell like the formula or breastmilk if they just fed, or potentially like sour milk if it’s been a while since a feeding.
However, if your baby is spitting up large amounts after every feeding, isn’t gaining weight on target and/or is crying when they spit up- this is not typically normal. Babies with reflux will often spit up milk that smells very acidic, almost like vinegar.
Sometimes babies with reflux will spit up very forcefully. This can sometimes be normal if it is occasional and after a large feeding, but if milk is being ejected vs dribbling out, it is typically a sign of reflux.
Do all babies with reflux spit up?
Unfortunately, no. It isn’t always that easy. So we can’t rely only on spitting as an indicator. This is called silent reflux. When a baby has silent reflux the acid comes up into their throat but they may swallow it back down. This is similar to the “heartburn” that adults experience.
For babies that have silent reflux, their parents and providers will need to rely on the other signs of reflux.
11 Signs of silent acid reflux in babies:
Spitting up is of course the most common sign of reflux, but far from the only one!
- Poor weight gain – this doesn’t always happen. But if a baby’s reflux is severe enough that the baby isn’t gaining weight then immediate intervention is needed.
- Cough that doesn’t go away – a baby with reflux may have a chronic sore throat from the acid. This may cause them to cough to try to relieve the feeling. They also might sound wheezy.
- Hiccups – When baby’s stomach acid flows back up into the esophagus, it can irritate the diaphragm. Hiccups are kind of a mystery but there is a correlation with reflux and hiccups.
- Blood in stool – because of the irritation in the stomach, there might be blood that comes out in a baby’s diaper. It might appear dark/black. Vs bright red blood which is typically an indicator of a bleed lower in the GI system
- ”The noise”– This is difficult to explain in writing. If I listen to a baby feeding, I can almost always immediately hear when a baby has reflux. I can hear it in their swallow. It’s a noisy, painful sounding swallow. The baby will often wince or sometimes cry when it happens.
- Arching back – This is a sign that your baby is upset. It could be from gas or something else as well.
- Smell – Babies may smell of vinegar or sickly and sour. Even if they aren’t spitting, you can still smell it in their mouths and sometimes in their stools.
- Crying when laid on back – When a baby with reflux is laid flat on their back the contents of their stomach can easily travel back up.
- Feeding aversions – Sometimes feeding causes babies so much discomfort that they cry at the breast or bottle. They may need to be coaxed into every feeding or fed while asleep or almost asleep.
- Hungry always – on the opposite end, sometimes milk can feel soothing on a baby’s throat and they want to eat constantly.
- Fussy and irritable– a baby with reflux might often be in discomfort and often in pain. For me, this is the biggest indicator that something needs to be resolved!
How is acid reflux treated:
Acid reflux is treated with babies a few ways, and they have varying levels of intervention. You can first try to treat reflux naturally by prevention.
Feeding schedule:
You might want to consider a feeding schedule. It can be difficult to figure out a rhythm if your baby has reflux because they may want to eat constantly… but also spit up constantly. Babies with reflux have a small stomach capacity and can’t do long stretches of sleep. It’s important to try to find a sweet spot between feedings. Both for the caregiver so that they don’t feel like they are constantly feeding, but also for the baby so their system can have rest and they can lie flat for sleep between feedings.
We’ve found that a consistent 2-3 hour schedule between feedings works best. You’ll need to work out what is best for your baby.
Feeding positions for a baby with reflux:
Babies with reflux should not be jostled during feedings and the baby should be positioned with their head above their bum.
If you are breastfeeding- you might want to try a laid back nursing position [biological nursing]. Or spending the extra moment to get comfortable before latching. Reflux babies don’t do well nursing on the go unfortunately.
If you are bottle feeding – we recommend feeding baby in an upright/paced feeding position or depending on their age and the arm strength of the caregiver, setting them up on a boppy to help reduce movement.
Burping a baby with reflux:
Babies with reflux often burp better in a sitting position vs over the shoulder or being patted. Pressure on their bellies will trigger milk to be evacuated!
Positioning a baby with reflux:
Babies with reflux need to be in an upright position after feedings. This might be for 10-15 minutes, or closer to 45 minutes for some babies.
Some friends might recommend inclining the crib. Please only do this under doctor recommendation and supervision. A baby needs to be inclined a minimum of 30 degrees to make a difference in reflux symptoms. In most scenarios there is not a safe way for a baby to sleep at this angle unsupervised. However a monitored reflux next is necessary in severe cases.
In certain cases doctors might also recommend belly sleeping, which puts less pressure on the sphincter.
We know that a baby lying flat on their back with no incline is a SIDS reducer and is recommended by the American Academy of Pediatrics.
Formula recommendations for reflux babies:
If your baby is drinking formula, you may want to consider trialing a different type of formula for 14-30 days. There are many different types of formula. For reflux parents typically need to consider that their baby might be having trouble digesting the proteins in their current formula.
Most formulas have a full milk protein. When those proteins are broken down slightly then the formula is called “partially hydrolyzed”. These formulas are often marketed as “colic” or “gentle” formulas. When they break the proteins down further it’s called “extensively hydrolyzed”. This is typically marketed as a “HA” formula or hypoallergenic formula and is usually around 90% broken down. When the protein is broken down to its most essential parts it’s called “amino acids”.
Examples of each formula: [Examples, not recommendations]
- Regular formula: Similac 360
- Partially Hydrolyzed: Enfamail Gentlease
- Extensively Hydrolyzed: Similac Alimentum
- Amino Acid Formula: EleCare
We have found that a HA Formula or a Goat’s Milk Formula are typically the most widely tolerated. If your baby needs an Amino Acid formula it might be covered by insurance.
Best acid reflux Medicine for babies:
All of the above recommendations are relatively “natural”. Medication might be a parent’s last resort, or it might be their first choice. That is a decision between a parent and their doctor.
It’s important to note that there are different types of acid reflux medication. They are mostly proton pump inhibitors (PPIs) and H2 receptor antagonists (H2RAs)
Proton pump inhibitors (PPIs): Omeprazole (Prilosec), Lansoprazole (Prevacid)
These work by reducing the amount of acid in baby’s stomach. It shuts down acid pumps in the stomach so there is less acid overall. They take time to take effect [typically a few days].
Histamine-2 blockers (H2RAs) : Ranitidine(Zantac), Famotidine (Pepcid), Nizatidine (Axid)
These neutralize the PH of the acid, but do not reduce the amount of acid. They have a faster onset, but aren’t always as effective.
There is no medication that is better or worse, it’s what works best for your baby. It is important to note that they are very weight dependent drugs, and babies grow every week. If it’s not working they might need a higher dose. Also your baby might do better on 3 doses throughout the day vs one or even two.
How to soothe baby acid reflux:
Babies with reflux often need extra love and support. They might want to be held all the time. These babies do very well with pacifiers and having something to suck on. Babies with reflux often can not work on sleep conditioning or stretching feedings. They need to focus on feeling comfortable as the main goal.
It can be difficult and overwhelming to know that your baby is in pain. It can also be physically challenging. If your baby is feeding every two hours and needs to be held for 45 minutes in between it might feel like you are never getting any rest.
It’s important to know when to ask for help. If you have a friend or family member who can give you naps during the day, or if you have the budget to hire overnight professional support, that can make all the difference for your mental and physical health.
