Up to 70% of babies will spit up some milk after their feeds. As long as they are otherwise happy and healthy, there is no reason to worry. 95% of infants grow out of reflux by 12-15 months. However, sometimes spitting up, also known as gastroesophageal reflux or GER, becomes excessive. In these cases, many parents want to know how to manage their infant’s reflux. In this article, I will cover natural ways to treat infant GER and why I advocate against the use of antacids for babies.
What Is Infant GER?
Infant GER or gastroesophageal reflux is also known as spitting up or posseting. It’s believed to most often be caused by a meal that’s too big for the baby’s stomach or by something in their meal that is irritating to them.
There are theories that reflux is beneficial to babies because it allows immunity enhancing breast milk to coat the esophagus thoroughly. There are other theories that reflux is caused by an immature sphincter. There are also theories that tongue or lip tie and resulting swallowing of air can contribute to reflux. At present, these are all just theories.
It is known that reflux is generally not acidic in babies in the same way that it is in adults. This is why antacids aren’t helpful in treating reflux.
Vomiting caused by illness is different and more forceful. There will be other signs of sickness. Projectile vomiting is also not considered reflux and may be a symptom of pyloric stenosis. Occasionally reflux is severe and causes problems with nutrient absorption and pain, this is termed gastroesophageal reflux disease or GERD.
Infant GER VS Infant GERD
Infant GER is uncomplicated reflux which is quite normal in babies. GERD or gastroesophageal reflux disease is more serious and involves a constellation of symptoms which includes reflux, but also excessive crying, poor weight gain, difficulty lying flat, coughing or difficulty swallowing, and breathing problems. It is important to remember that colic and GER can occur together and that many of these symptoms overlap with symptoms of colic (excessive crying, difficulty lying flat) and poor latching (poor weight gain, coughing or difficulty swallowing). It is important to rule out those causes before accepting a diagnosis of GERD.
Natural Management Of Infant GER
- Infant Positioning. Keep baby in an upright position during and after feeding. Avoid car seats and baby seats immediately after feeding if possible. In some cases, the baby’s position in the seat can compress their abdomen and worsen reflux.
- Infant Feeding. If breastfeeding, work with a lactation consultant to ensure that the latch is good. International BreastFeeding Centre is my favorite resource for lactation information. They have great videos about latching. Consider smaller and more frequent meals.
- Burp Baby. Burping baby regularly after meals may help reduce reflux.
- Check for Allergens. If breastfeeding, mom can try an elimination diet to see if something that she’s eating is bothering her baby. Dairy is the most common culprit. Gluten, eggs, caffeine, garlic, onions, broccoli, and soy are other common problems. If the baby is partially or exclusively formula fed, check out my article on FPIES to see if the baby has other symptoms. Switching formulas to a hydrolyzed or extensively hydrolyzed protein formula may be helpful.
- Probiotics. The research into probiotics for infant reflux is still in its infancy, but there’s an indication that they may be helpful in some cases. High quality, infant-specific probiotics are quite safe and have plenty of side benefits for infants.
- Gripe Water. Gripe water is a popular herbal preparation for infants that contains sterile water along with sodium bicarbonate and a combination of herbs that might include fennel, dill, chamomile, licorice, ginger, and mint. Gripe water won’t treat the cause of reflux, but it can offer some relief to a fussy baby and by soothing and protecting their digestive tract. Sodium bicarbonate can act as an antacid and may be helpful for GERD if the reflux is acidic.
- Massage, Chiropractic, Craniosacral, or Osteopathic Care. Though no large scale studies have been done, there are case reports and anecdotal evidence that manual therapies can help with the resolution of infant reflux. It is important to find a therapist who is skilled and experienced with infant treatment.
Treatments To Avoid For GER
The two most commonly prescribed treatments for infant reflux are antacids and food thickeners like rice cereal or sodium alginate. These treatments don’t have much evidence for efficacy and can cause short and long term side effects.
Antacids
Antacids aren’t helpful for GER and cause side effects like constipation, nausea, headaches, and diarrhea in 23-34% of children. Antacids reduce the ability of the body to break down proteins and may contribute to the development of food allergies and intolerances. Antacid use is also linked to increased risk of developing asthma and an increased risk of fractures.
Thickeners
Thickeners may help bottle-fed babies with reflux keep their meals down. However, if reflux is caused by too large of meals or by food allergens, then keeping it down with a thickener isn’t a wise first choice of treatment. The above modifications to diet and positioning should be tried first in most cases. Thickeners don’t usually work as well in breast milk because the enzymes in breast milk break them down quickly.
If using a thickener, The American Academy of Pediatrics (AAP) now recommends oatmeal cereal—not rice cereal—if a thickener is truly needed. This shift is due to concerns about arsenic exposure from rice products, especially in babies who would be consuming them frequently and at a stage of rapid development.
Tips from the AAP for using oatmeal cereal:
- Mix oatmeal into pumped breast milk or formula shortly before feeding to prevent breakdown of the thickener by enzymes in breast milk.
- If bottle-feeding, you may need to use a faster flow nipple or a commercially precut cross-cut nipple.
- Position your baby appropriately during feeds to make swallowing easier and reduce reflux.
- Avoid overfeeding. Smaller, more frequent meals often help with reflux symptoms.
While oatmeal is considered the safer choice, it’s worth noting that conventionally grown oats can contain glyphosate, a common herbicide. According to testing by the Environmental Working Group (EWG), glyphosate levels in oat-based baby cereals have dropped in recent years. The highest glyphosate levels were found in certain Beech-Nut oatmeal baby cereals, while no glyphosate was detected in several Gerber oatmeal products.
If you prefer to avoid commercially processed baby cereals altogether, you can make your own by very finely grinding organic, sprouted oats, such as those from One Degree Organics, into a fine powder. Oats are naturally gluten-free, but they can sometimes come into contact with gluten during processing. The oats in this product are certified gluten-free, meaning they’ve been handled carefully from field to package to avoid cross-contamination.
It is important to note that homemade oatmeal cereal won’t be iron-fortified, while infant oat cereal likely will be. If iron is needed, it could be supplied via a high-quality supplement instead.
When my daughter was a baby, there was a recall and subsequent lawsuit for the makers of SimplyThick – a thickening agent used to treat reflux which was later linked to illness and death of many babies. It was on the market and causing harm for years before the lawsuit. Just because something is FDA approved, doesn’t necessarily mean it is safe.
Summary
Infant reflux is very common and rarely requires treatment. Changes in baby’s position, changes in feeding, removing allergens, probiotics, herbal therapies, and manual therapies may all be helpful for managing symptoms. Antacids aren’t usually helpful and come with a host of short and long term side effects. Thickeners may be helpful in bottle fed infants, but shouldn’t be a first choice for treatment. Most babies outgrow reflux by 12-15 months of age.
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