In the early weeks, it is normal for a baby to “spit-up” and around half of all newborns do, at least once a day. As a baby’s digestive system matures, this usually decreases and for most mothers it is just a short-term inconvenience. 1
However, in some babies the valve between the stomach and oesophagus does not close properly. The stomach contents flow back into the oesophagus and can cause vomiting. There are several reasons a baby may vomit and a doctor will need to rule out other causes, but one possible diagnosis is GERD (gastroesophageal reflux disease), also referred to as GOR (gastro-oesophageal reflux).
Not all reflux is noticeable and it doesn’t always make a baby uncomfortable, but when it’s severe it can be painful and cause distress to mother and baby.2
What are the signs to look out for?
- A baby may choke and cough, or seem to have a sore throat. Some babies have bad breath.
- A mother may notice back arching and head turning. The baby may stretch out flat as this reduces pain, instead of snuggling close to his mother.
- A baby may cry for long periods and be irritable during and after feeds. His cries may sound hoarse. This sometimes leads to a misdiagnosis of colic.
- A baby may seem to fight feeding or even refuse to feed. There may be poor weight gain.
What might help?
A few things may help lessen pain. Keeping the baby’s head higher than his bottom during feeding can be more comfortable for him/her. Being at a 30 to 40 degree angle with the baby’s bottom in the mother’s lap and his torso supported on the mother’s crossed leg may be one way for the baby to feed more comfortably. If the baby is feeding in a side-lying position then s/he may feed better on the left side; moving the baby over instead of turning him round if changing sides. It’s preferable to move the baby to a more upright position as soon as possible. 3
It can be useful to consider “head above bottom” at all times. A baby sling can be helpful for this purpose. A baby with reflux may find it uncomfortable to lay down flat and might cry or spit up when laid in a cot. Some parents choose to keep their baby in their arms or a sling for naps. Others find it helps to keep their baby upright for a period of time after feeds before they lay them down.
Changing the baby on his side may be preferable to avoid putting pressure on his stomach when lifting his legs. A lay-back bouncy seat can be useful. Babies with reflux can find travelling in a car seat uncomfortable due to the pressure on their stomachs and some mothers choose to use the car less while it distresses the baby and instead use public transport while carrying the baby in a sling.
As the opening from the stomach to the oesophagus is usually on the right side, keeping the right side higher than the left may also help.
Short, frequent feeds ease the incidence and discomfort of reflux. 4 If a mother has a copious milk supply then feeding one side only at each feed may ease discomfort. However, it is worth looking at what seems to suit your baby.
What causes reflux?
There are several suggestions as to why reflux happens. It’s sometimes suggested that it’s caused by an immature sphincter muscle 5 and that this will strengthen as the baby grows.
Other studies have shown a link between reflux and allergies, or an intolerance to cows’ milk protein. 6 A mother could try to remove dairy products from her diet, in consultation with a medical professional, to see if that improves things.
One of the biggest causes can be fast-flowing milk or oversupply. If a baby seems to be choking or gasping because of a fast flow, there are several things to try. You can take him off the breast for a moment until the flow slows, or feed in a more upright position.
Making sure a baby has a deep latch and good tongue function can also make a difference. Tongue-tie can affect a baby’s sucking action and can lead to a baby swallowing too much air. You can find further suggestions here:
Adding solids to “thicken feeds” has significant drawbacks
It is sometimes suggested that babies with reflux will be helped by adding solids to their diet to thicken feeds. In 2018, a study in the British Medical Journal reported that “Feed thickeners are commonly used for managing infants with GOR despite the lack of strong supporting evidence”.7 As most existing studies assessing the efficacy of thickened feeds on reflux symptoms mainly include formula-fed infants, there is limited information available on the potential reduction of regurgitation in breastfed babies.8
Aside from the lack of strong evidence, this treatment has some significant drawbacks. Introducing solid food too early replaces human milk, which is nutritionally ideal for babies, with a food of less nutritional value. It will also lower a mother’s milk supply. Regurgitating solids can add to the baby’s distress and discomfort, and introducing solids too early might also trigger allergies in an already sensitive baby.
Switching to formula may not be the answer
Although it is sometimes suggested that breastfeeding mothers change to formula, this may well worsen symptoms. While both breastfed and formula fed babies can experience reflux, research has shown that formula fed infants have episodes of reflux more often than breastfed babies and they last longer.9
As one cause of reflux can be a delayed emptying of the stomach, the fact that human milk leaves the stomach twice as quickly as formula means that breastmilk lessens the possibility of reflux. 10
If nothing seems to work
If a baby continues to be distressed, then a doctor may refer you to a gastroenterologist who may prescribe medications which can help.
In his Guide to Breastfeeding, 11 Dr. Jack Newman, a member of La Leche League International’s Panel of Professional Advisors, explains how breastmilk is full of immune factors that interact with each other and protect the baby from bacteria, viruses and other micro-organisms.
They work by forming a protective layer on a baby’s mucous membranes which line the gut, respiratory tract and other areas. This stops micro-organisms from invading the body through these mucous membranes. Dr. Newman explains that a baby who spits up gets double protection, first when the milk goes down to the stomach, and again when he spits it up.
If you would like further help and support look for your nearest LLL group or Leader.
You can find further information here:
Written by Anna Burbidge, LLLGB 2019
1 Nancy Mohrbacher, “Breastfeeding Answers Made Simple. A Pocket Guide for Helping Mothers”, (http://www.lllgbbooks.co.uk/store/p94/Breastfeeding_Answers_Made_Simple%3A_A_Pocket_Guide_for_Helping_Mothers.html)
2 La Leche League International, “The Womanly Art of Breastfeeding”, 8th Edition, 2010, p. 417. (http://www.lllgbbooks.co.uk/store/p91/The_Womanly_Art_of_Breastfeeding.html)
3 Boekel, S. “Gastro-esophageal reflux disease (GERD) and the breastfeeding baby”, ILCA Independent Study Module. Raleigh, North Carolina: International Lactation Consultant Association, 2000.
4 La Leche League International, “The Womanly Art of Breastfeeding”, 8th Edition, 2010, p. 417. (http://www.lllgbbooks.co.uk/store/p91/The_Womanly_Art_of_Breastfeeding.html)
6 Nancy Mohrbacher, “Breastfeeding Answers Made Simple”, 2010, pp. 517-520. (http://www.lllgbbooks.co.uk/store/p93/Breastfeeding_Answers_Made_Simple.html)
7 T’ng Chang Kwok, Shalini Ojha and Jon Dorling: “Feed thickeners in gastro-oesophageal reflux in infants”, BMJ Paediatrics Open 2018 (https://bmjpaedsopen.bmj.com/content/2/1/e000262)
8 Kwok TC, Ojha S, Dorling J.: “Feed thickener for infants up to six months of age with gastro‐oesophageal reflux.” Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD003211. (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003211.pub2/full)
9 Hegar B. et al: “Natural evolution of regurgitation in healthy infant.s” Acta Paediatrica 2009; 98(7): 1189-1193 (https://doi.org/10.1111/j.1651-2227.2009.01306.x)
10 Ewer, A. et al: “Gastric emptying in preterm infants”, Arch Dis Child 1994; 71:F24-F27.
11 Dr. Jack Newman and Teresa Pitman: “Dr. Jack Newman’s Guide to Breastfeeding”, Revised Edition 2014 (https://www.amazon.co.uk/dp/1780662300/?tag=breastfsuppor-21)
- Trikha, A.,Baillargeon, J. G.,Kuo, Y. F.,Tan, A.,Pierson, K.,Sharma, G.,Wilkinson, G.,Bonds, R. S. “Development of food allergies in patients with Gastroesophageal Reflux Disease treated with gastric acid suppressive medications..” Pediatr Allergy Immunol 2013 Sep; 24 (6): 582-8
- Smyth C, Why Infant Reflux Matters, Pinter and Martin 2021