Infant Reflux: When to Worry or Not

Reflux or “spitting up” of an infant is one of the many concerns of parents because of its frequent occurrence.   It is usually harmless and does not require treatment.  However, there are occasions when reflux can lead to serious health issues and babies will need monitoring and treatment by pediatricians.  

So, when should spit-up be a concern?

Happy spitters vs Cranky spitters

Spitting up can be seen in happy, healthy infants who have no feeding difficulty or no trouble sleeping.  They thrive well with good weight gain.  This is known as gastroesophageal reflux (GER) or simply, infant reflux or regurgitation^1,2,3. Almost half of infants experience reflux and /or vomiting without any consequences.  It is mostly seen among babies 0-12 months old and spontaneously resolves without any distress³.  

When the spit-up becomes significant enough to cause problems and complications, the condition then becomes pathologic and is now termed gastroesophageal reflux disease (GERD)^1,2,3.  These are the cranky spitters that cause so much parental concern and anxiety.  Such babies who manifest with the following red flags^1,2 should immediately see a pediatrician:

• Refusal to feed
• Failure to gain weight
• Irritability  
• Sleep disturbance
• Vomiting with blood that is red, brown, or green
• Recurrent coughing with or without difficulty of breathing
• Persistent spitting beyond infancy

What causes infant reflux?

Reflux happens when food in the stomach, including acid and non-acid secretion, flows back up into the esophagus due to transient relaxation to underdeveloped or incompetent of the lower esophageal sphincter^1,2 – a muscle valve in between the esophagus and stomach.  Reflux should be differentiated from vomiting which is a forceful expulsion of stomach contents.  Stress during serious illnesses, overfeeding, certain medications and sometimes, even milk can trigger or aggravate reflux.  Some of the infant populations who have increased risk for reflux include premature infants, babies who are neurologically impaired or have chronic lung problems congenital heart disease, those who underwent esophageal surgery and overweight/obese babies^1,2.  

How to manage reflux?  

There are supportive measures that can be done for both happy and cranky spitters which include the following:

Upright position and burping
Maintaining babies in an upright posture for at least 30 minutes after feeding can help facilitate faster emptying of stomach contents⁴. Burping babies after feeding can help prevent air and gas from building up in the tummy.  

Feeding
Small frequent feedings may be more helpful than large feeding with long intervals_¹.  Certain powdered milk may be beneficial and good for non-breastfed babies with reflux.  These include anti-reflux thickened formulas⁵ and hypoallergenic milk which may help improve reflux symptoms similar to those caused by protein intolerance^1,6.  Low fat milk, such as plant-based milk, may also relieve reflux symptoms^7,8 and may be used under medical supervision. Another good option for reflux is plant-based milk that is low in fat.  

Medications
Babies who have the pathologic type of reflux or GERD will need medications that can help reduce stomach acid production or hasten emptying of stomach contents¹.  

When to seek help?  

The presence of red flags should always prompt consultation with a healthcare professional.  Parents who remain anxious about their infants who do not improve with supportive measures should likewise seek help.  

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