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How To Manage Infant Reflux Without Using Antacids

in Growth & Development, Gut Health

Up to 70% of babies will spit up some milk after their feeds, and 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

  1. 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.
  2. 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. 
  3. Burp Baby. Burping baby regularly after meals may help reduce reflux. 
  4. 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.
  5. 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. 
  6. 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. 
  7. 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 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 work well in breast milk because the enzymes in breast milk break them down quickly. 

If choosing a thickener, I recommend rice cereal over other thickening agents. It is easier on babies’ intestines and seems safest based on what I know. 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 for 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. 

References:

Corvaglia, L., Mariani, E., Aceti, A., Galletti, S., & Faldella, G. (2013). Extensively hydrolyzed protein formula reduces acid gastro-esophageal reflux in symptomatic preterm infants. Early human development, 89(7), 453–455. https://doi.org/10.1016/j.earlhumdev.2013.04.003 

Untersmayr, E., Schöll, I., Swoboda, I., Beil, W. J., Förster-Waldl, E., Walter, F., Riemer, A., Kraml, G., Kinaciyan, T., Spitzauer, S., Boltz-Nitulescu, G., Scheiner, O., & Jensen-Jarolim, E. (2003). Antacid medication inhibits digestion of dietary proteins and causes food allergy: a fish allergy model in BALB/c mice. The Journal of allergy and clinical immunology, 112(3), 616–623. https://doi.org/10.1016/s0091-6749(03)01719-6

Cohen, S., Bueno de Mesquita, M., & Mimouni, F. B. (2015). Adverse effects reported in the use of gastroesophageal reflux disease treatments in children: a 10 years literature review. British journal of clinical pharmacology, 80(2), 200–208. https://doi.org/10.1111/bcp.12619

Baird, D. C., Harker, D. J., & Karmes, A. S. (2015). Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children. American family physician, 92(8), 705–714.

Depoorter, L., & Vandenplas, Y. (2021). Probiotics in Pediatrics. A Review and Practical Guide. Nutrients, 13(7), 2176. https://doi.org/10.3390/nu13072176

Capozza, M., Laforgia, N., Rizzo, V., Salvatore, S., Guandalini, S., & Baldassarre, M. (2022). Probiotics and Functional Gastrointestinal Disorders in Pediatric Age: A Narrative Review. Frontiers in pediatrics, 10, 805466. https://doi.org/10.3389/fped.2022.805466

Hassall E. (2012). Over-prescription of acid-suppressing medications in infants: how it came about, why it’s wrong, and what to do about it. The Journal of pediatrics, 160(2), 193–198. https://doi.org/10.1016/j.jpeds.2011.08.067

Untersmayr, E., & Jensen-Jarolim, E. (2008). The role of protein digestibility and antacids on food allergy outcomes. The Journal of allergy and clinical immunology, 121(6), 1301–1310. https://doi.org/10.1016/j.jaci.2008.04.025

Trikha, A., Baillargeon, J. G., Kuo, Y. F., Tan, A., Pierson, K., Sharma, G., Wilkinson, G., & Bonds, R. S. (2013). Development of food allergies in patients with gastroesophageal reflux disease treated with gastric acid suppressive medications. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology, 24(6), 582–588. https://doi.org/10.1111/pai.12103

Wang Y, Wintzell V, Ludvigsson JF, Svanström H, Pasternak B. Association Between Proton Pump Inhibitor Use and Risk of Asthma in Children. JAMA Pediatr. 2021;175(4):394–403. doi:10.1001/jamapediatrics.2020.5710

Laura Malchodi, Kari Wagner, Apryl Susi, Gregory Gorman, Elizabeth Hisle-Gorman; Early Acid Suppression Therapy Exposure and Fracture in Young Children. Pediatrics July 2019; 144 (1): e20182625. 10.1542/peds.2018-2625

Alcantara, J., & Anderson, R. (2008). Chiropractic care of a pediatric patient with symptoms associated with gastroesophageal reflux disease, fuss-cry-irritability with sleep disorder syndrome and irritable infant syndrome of musculoskeletal origin. The Journal of the Canadian Chiropractic Association, 52(4), 248–255.

Angus, K., Asgharifar, S., & Gleberzon, B. (2015). What effect does chiropractic treatment have on gastrointestinal (GI) disorders: a narrative review of the literature. The Journal of the Canadian Chiropractic Association, 59(2), 122–133.

Neu, M., Pan, Z., Workman, R., Marcheggiani-Howard, C., Furuta, G., & Laudenslager, M. L. (2014). Benefits of massage therapy for infants with symptoms of gastroesophageal reflux disease. Biological research for nursing, 16(4), 387–397. https://doi.org/10.1177/1099800413516187

Neu, M., Schmiege, S. J., Pan, Z., Fehringer, K., Workman, R., Marcheggianni-Howard, C., & Furuta, G. T. (2014). Interactions during feeding with mothers and their infants with symptoms of gastroesophageal reflux. Journal of alternative and complementary medicine (New York, N.Y.), 20(6), 493–499. https://doi.org/10.1089/acm.2013.0223

Mills M. V. (2021). The use of osteopathic manipulative treatment in the newborn nursery and its effect on health in the first six months of life: A retrospective observational case-control study. Complementary therapies in clinical practice, 43, 101357. https://doi.org/10.1016/j.ctcp.2021.101357

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