Understanding Baby Reflux: Signs, Symptoms, and How to Manage It While Feeding

One of the most common visit types I have in clinic is due to frequent spit-ups in infants.

While spit-up can be worrying for parents, most reflux does not require medical treatment.

This blog post will guide you through the signs and symptoms of reflux, the differences between typical spit-up and gastroesophageal reflux disease (GERD), how reflux presents in both breastfed and bottle-fed babies, and when to consider interventions like medications or anti-reflux formulas.

What Causes Spit Up and GERD in Babies?

Reflux in babies occurs because the lower esophageal sphincter, the muscle between the esophagus and the stomach has not fully developed. This causes the contents of the stomach to come back up.

Most infants experience some degree of reflux, which can present as:

• Frequent Spitting Up

• Irritability During/After Feedings

• Coughing or Gagging

• Poor Weight Gain

• Sleep Difficulties

For many babies, reflux or spit-up is a part of life, however, if symptoms become more severe, it is time to ask for help.

GERD vs. Spit-Up in Babies: What’s the Difference?

While all babies spit up to some extent, not all cases are severe enough to be considered GERD. Here’s how to distinguish between the two:

• Spit-Up (Physiological Reflux): Spit-up is normal in infants. It usually doesn’t cause distress and occurs in otherwise healthy, growing babies. It is normal for a baby to spit up multiple times per day without concern, especially if they are laid down flat after a feed. This type of reflux is generally harmless and peaks between 2-4 months of age.

• GERD (Gastroesophageal Reflux Disease): GERD is a more serious form of reflux that may cause significant discomfort, irritability, or feeding difficulties. Symptoms of GERD include excessive crying, poor weight gain, coughing, choking, and difficulty sleeping. GERD should be evaluated by a medical provider and may require medical treatment.

If your baby is thriving and generally content despite frequent spit-up, they likely have typical reflux rather than GERD. You may hear your pediatric provider refer to your baby as a “happy spitter.”

Signs and symptoms of GERD in Babies

The signs and symptoms of reflux in babies can vary, but common indicators include:

• Frequent Spitting Up: This is the most noticeable symptom, where milk or formula comes back up, either shortly after feeding or even an hour or two later.

• Irritability During or After Feedings: Babies with reflux may become fussy or seem uncomfortable when eating or right afterward, often arching their back or crying.

• Coughing, Gagging, or Hiccups: Reflux can cause irritation in the throat, leading to these symptoms, especially after feeding.

• Poor Weight Gain: In severe cases, babies may not gain enough weight due to frequent spit-up or feeding difficulties.

• Refusal to Eat or Difficulty Eating: Babies might refuse feedings or have trouble feeding because of the discomfort from reflux.

• Excessive Drooling or Wet Burps: Saliva may increase due to irritation, and babies may have more "wet" burps where small amounts of milk come back up.

• Disrupted Sleep: Lying down can exacerbate reflux symptoms, causing discomfort and sleep disturbances.

Reflux vs. Colic: What's the Difference?

 Reflux and colic are often confused because both can cause a baby to be fussy or uncomfortable, but they are two distinct conditions:

Reflux:

• Cause: Reflux occurs when stomach contents flow back into the esophagus, causing discomfort, frequent spit-up, or vomiting. It often leads to visible signs like regurgitation, arching of the back, irritability during or after feedings, and sometimes poor weight gain.

• Symptoms: Babies with reflux often have episodes of spitting up, appear uncomfortable after eating, and may cry due to the discomfort of acid moving up the esophagus.

• Management: Reflux symptoms typically improve with feeding adjustments (e.g., keeping the baby upright after feeding, offering smaller feedings), using anti-reflux formula, or medication.

Colic:

• Cause: The exact cause of colic is unknown, but it’s characterized by prolonged periods of intense, inconsolable crying in an otherwise healthy baby. Colic usually appears around 2-3 weeks of age and peaks around 6-8 weeks, resolving by about 3-4 months.

• Symptoms: Babies with colic cry for at least three hours a day, three days a week, for three weeks or more. The crying episodes are often worse in the late afternoon or evening and may not be linked to feedings or other clear causes.

• Management: Colic isn’t related to feeding and doesn’t respond to medication or changes in formula. Soothing techniques like swaddling, white noise, or motion are commonly used. There is some evidence that certain probiotics may improve symptoms of colic.

While both reflux and colic can cause significant distress for babies and their parents, the key difference is that reflux is associated with feeding and digestion, whereas colic involves prolonged crying without an obvious cause.

If your baby has frequent spit-up along with irritability, it’s more likely reflux.

If the fussiness occurs at predictable times without spit-up, colic could be the culprit.

If your baby has symptoms of colic, it is important to speak with your pediatric provider to rule out Cow Milk Protein Allergies (CMPA) <<< click to read more about CMPA.

Reflux vs. Overfeeding: How to Tell the Difference

Many parents wonder if their baby’s spit-up is due to reflux or overfeeding. Overfeeding occurs when a baby takes in more milk or formula than their stomach can handle at one time.

Signs of Overfeeding:

• Spit-up that occurs immediately after large feedings.

• The baby is generally content and shows no other signs of distress after spitting up.

• The spit-up is usually a small amount relative to the feeding.
  

Signs of Reflux:

• Spit-up occurs after both small and large feedings.

• The baby may appear fussy or uncomfortable after eating.

• Spitting up more than once after each feeding.

To prevent overfeeding, pay attention to your baby’s hunger and fullness cues, and consider feeding smaller amounts more frequently if spit-up is an issue.

How to Handle Reflux in Breastfed Babies

When a breastfed baby has symptoms of reflux, I always ask the following questions:

• Does mom have oversupply?

• Is there a forceful letdown?

• Does baby cough, sputter or pour milk from the sides of the mouth while feeding?

• Does baby latch and unlatch frequently?

• Is baby very gassy?

If the answer to any of these questions is yes, I recommend trialing reclined feeding at a 45-degree angle to see if it helps with reflux symptoms or regurgitation.

You can consider seeing a feeding professional or scheduling a consult.

Here are other adjustments that may alleviate symptoms:

• Keep Baby Upright: Holding your baby upright during and after feedings for 20-30 minutes can help reduce reflux episodes.

• Frequent, Smaller Feedings: Breastfed babies naturally take in smaller amounts, but offering more frequent feedings may help prevent overfilling their stomach.

• Burp Regularly: Burp your baby in the middle of and after feedings to release trapped air, which can cause discomfort and worsen reflux.

• Dietary Adjustments: While most moms won’t need to change their diet, some may notice that certain foods, like dairy, can exacerbate reflux in their baby. You can do a trial without dairy to see if there is an improvement in reflux symptoms. You should notice a change within 3-5 days if dairy is making symptoms worse.

Breastfed babies with reflux often do well with these minor adjustments, but if symptoms persist, consult your pediatric provider.

How to Handle Reflux in Bottle-Fed Babies

Bottle-fed babies may experience more frequent episodes of reflux due to the nature of formula digestion. Here's how to manage reflux in bottle-fed infants:

• Use Anti-Reflux Bottles: Some bottles are designed to reduce the amount of air babies swallow while feeding, which can decrease gas and spit-up. Make sure your baby has a seal around the bottle nipple and that milk is not pouring from the sides. Different babies do better with different bottles based on their mouth shapes.

• Choose the Correct Flow: Babies who guzzle bottles may overeat, causing reflux symptoms. Bottle nipple flow rates may be too fast. If your baby guzzles, chugs, or finishes a bottle quicker than you’d expect, you may consider decreasing the flow rate.

• Frequent Burping: Bottle-fed infants should be burped frequently during feedings to minimize trapped gas.

• Formula Change: Prior to starting thickened feeds, your pediatric provider may recommend a gentle or sensitive formula.

Click here to get personalized formula recommendations based on your baby’s needs.

Does Your Baby Need Medication or Thickened Formula?

If your baby has more severe reflux symptoms, you may wonder whether medication or a change in formula is necessary.

• Medication: For babies with GERD or severe discomfort, your pediatrician may prescribe an acid-reducing medication, such as a proton pump inhibitor (PPI) or an H2 blocker. These medications work by reducing the stomach acid that irritates the esophagus.

• Thickened Formula: For babies who spit up frequently but don’t require medication, thickened formula can be a helpful option. 

Anti-Reflux Formula: What’s Inside and How Does It Work?

Anti-reflux formulas are specially designed to reduce the amount of milk that is regurgitated after feeding. They are often a solution for babies who are formula-fed and experience significant reflux symptoms.

Here’s how anti-reflux formulas work and their unique composition:

1. Thickening Agents: Anti-reflux formulas contain added thickeners such as rice starch, cornstarch, or locust bean gum. These ingredients cause the formula to become thicker in the stomach, which helps keep the contents from coming back up into the esophagus. While these thickeners help with reflux, they may increase the calorie content and lead to constipation in some babies.

2. Proteins: Some anti-reflux formulas also use partially hydrolyzed proteins or whey protein instead of casein-dominant formulas. Whey protein is easier for babies to digest and may cause less reflux than casein, which forms curds in the stomach.

3. Carbohydrates: The carbohydrate sources in anti-reflux formulas may vary. In most anti-reflux formulas, lactose is still the main carbohydrate, as it is naturally present in breastmilk. However, some specialized formulas may reduce lactose content to minimize gas or discomfort in babies sensitive to dairy.

4. Prebiotics and Probiotics: Some anti-reflux formulas include prebiotics and probiotics to support gut health and digestion. These can help regulate a baby’s bowel movements and reduce any digestive discomfort that may worsen reflux.

Popular brands like Enfamil AR and Similac for Spit-Up contain rice starch to thicken the formula, but each brand has its own specific composition. You may also talk to your pediatric provider about adding a thickener to a regular or gentle formula.

Before switching to an anti-reflux formula, consult your pediatric provider to determine if it’s the right solution for your baby’s reflux.

When Do Babies Stop Spitting Up as Much?

Most babies start to spit up less frequently as they approach 6 to 9 months old, with significant improvement by their first birthday. Several developmental milestones help reduce spit-up episodes:

• Stronger Muscles: As your baby’s muscles, including the lower esophageal sphincter, strengthen with age, they are better able to keep food in the stomach.

• Sitting Up: Babies who can sit up on their own, typically around 6 months, experience less reflux because gravity helps keep milk or formula down.

• Introduction of Solids: Solid foods tend to stay in the stomach longer than liquids, which can help decrease spit-up.

• Improved Digestion: As your baby's digestive system matures, they become more efficient at processing feedings without reflux.

By 12 to 18 months, most babies have outgrown the spitting-up phase altogether, and it’s no longer a daily issue.

If spit-up persists beyond this time or is accompanied by other concerning symptoms, it’s a good idea to consult your pediatrician to rule out any underlying conditions.

Reflux is a common part of infancy, but there are ways to manage your baby’s symptoms, whether they are breastfed or bottle-fed. Most babies will outgrow reflux by their first birthday, but in more severe cases, medications or specialized formulas may be needed.

If your baby is showing signs of reflux, don’t hesitate to consult your pediatric provider for personalized advice on how to best support their feeding journey. Anti-reflux formulas, feeding adjustments, and in some cases, medications, can make a significant difference in your baby’s comfort and overall health.

Sources:

1. American Academy of Pediatrics: "Spitting Up in Babies" – Information on reflux and when babies typically outgrow it.

2. Mayo Clinic: "Infant Reflux" – Detailed overview of symptoms, causes, and treatments for reflux in babies.

3. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): "Gastroesophageal Reflux (GER) in Infants" – Discusses the difference between GER and GERD in infants.

4. Cleveland Clinic: "GERD in Infants" – Provides insights on GERD symptoms and treatments, including anti-reflux formulas.

5. HealthyChildren.org (AAP): "Reflux and GERD in Babies" – Tips on handling reflux in babies and when they typically outgrow it.