Reflux – infant & child

Also known as spilling or spitting up

In babies, 'spilling' or 'spitting up' stomach contents is a normal process that helps to relieve an uncomfortably full stomach. More than 50% of babies spill regularly in the first months of life. While spilling generally does not need medical treatment, there are a few things you can do to cope with your baby's spilling.

Key points about reflux in infants

  1. All babies experience some degree of spilling or reflux, because their digestive systems (gut) are not yet fully developed.
  2. Most children outgrow spilling, between 6 and 12 months. It generally improves as baby becomes more upright, the diet becomes more solid, and the gut function matures.
  3. If you child is older than 1 year and is still spilling, read more about gastric reflux remaining into childhood
  4. As long as your baby is healthy and growing normally, spilling should not be a cause for concern.
  5. A more-severe form of reflux, known as gastro-oesophageal reflux (called GOR), is rare. Symptoms of GOR include frequent vomiting and regurgitation, poor weight gain and tummy pain. If you are concerned your baby may have GOR, see your doctor for diagnosis and treatment.

What causes spilling?

Spilling happens when the stomach contents are released back up into the swallowing pipe (oesophagus). 

  • There is a ring of muscle at the top of the stomach that should close when feeding stops. In babies and young children this valve is underdeveloped and may not close properly, causing food and digestive acids to leak back up from their stomach into the oesophagus. 
  • Sometimes, but not always, milk spills out the mouth. 
  • Spilling usually happens after feeding, however, it can also occur when your baby cries, coughs, or strains. 

In rare cases, gastric reflux symptoms could be caused by something different:

  • Allergic gastroenteritis
    • This is an intolerance to an ingredient in food, normally a protein in cow's milk.
  • Gastro-oesophageal reflux disease (GORD)
    • This is an inflammation of the lining of the oesophagus due to stomach acid leaking up (refluxing) from the stomach.
  • Eosinophilic oesophagitis
    • This occurs when a specific kind of white blood cell (eosinophil) gathers and damages the lining of the oesophagus.
  • Gut obstruction    
    • This is narrowing or blocking of the oesophagus (swallowing tube) or narrowing or blocking in-between the small intestine and stomach (pyloric stenosis).

When to see a doctor

undefinedAs long as your baby is healthy and growing normally, spilling should not be a cause for concern. Spilling or reflux is different to vomiting. Spilling is effortless, while vomiting is forceful. More severe cases of reflux can cause frequent vomiting and regurgitation, and poor weight gain.

Contact your family doctor if your baby:

  • is bringing up a large amount of milk after most feeds
  • seems to be in pain after breastfeeds
  • spits up forcefully (projectile vomiting)
  • spits up green or yellow fluid
  • is fussy and unhappy between feeds
  • arches her back or seems to be in pain after most feeds
  • has problems gaining weight (is not gaining weight or has small weight gains)
  • has ongoing breathing problems
  • starts vomiting at age 6 months or older.

Irritability and crying

Reflux is commonly blamed for causing irritability in babies. However, it is very normal for babies to wake frequently and cry lots: 

  • for the first few weeks after birth, newborns are often very sleepy
  • around 2 weeks of age they 'wake up' and crying generally increases
  • crying commonly peaks at age 6 to 8 weeks.

Listening to you baby cry can be very distressing, especially if your baby is very irritable and cries excessively. Some parent worry that their may be a medical reason for their babies crying. Up to 20% of parents report a problem with infant crying or irritability in the first 3 months of parenthood. However, in most cases, no medical intervention is required.

How long does reflux last?

  • Spilling usually begins before babies are 8 weeks old and may get worse until approximately 4 months of age.
  • Most babies get better before they are 1 year old, as they becomes more upright, the diet becomes more solid, and the gut function matures.
  • If you child is older than 1 year and is still spilling, read more about gastric reflux remaining into childhood.

What are the treatment options for spilling?

Spilling does not usually need any special tests or treatment, but while your baby’s digestive system is still developing, there a few things you can try to cope with spilling.

 

 Tips on how to cope with spilling

Position
  • While it is important for your baby to sleep on their backs (to prevent sudden infant death syndrome), avoid feeding your baby in a lying-down position. Try to keep your baby’s head upright while feeding.
  • Keep you baby upright for 30 minutes after each feed – usually over your shoulder. Avoid the ‘car seat position’ after feeding, because sitting can make reflux worse in babies.
  • Raise the head end of the cot so your baby’s head is higher than their legs. Do this by putting thick books beneath the cot legs, or put a folded towel under the head end of the mattress (do not use a pillow with any baby less than one year old). 
Feed smaller amounts more frequently 
  • Avoid feeding too much at one time. Give your baby smaller feeds more often, unless the feeds are already small and frequent.
Burping or winding
  • Burp or wind your baby a few times during each feeding. Do it when they pause and look around. Don't interrupt their feeding rhythm in order to burp them.
  • Burp each time for less than a minute. Stop even if no burp occurs. Some babies don't need to burp.
Formula
  • If your baby is bottle fed, try changing to a hypoallegenic formula.The symptoms of cow's milk allergy or intolerance can be very similar to the symptoms of reflux. 
  • Sucking on a bottle with too small a nipple hole can cause the stomach to fill with air. If the formula doesn't drip out at a rate of 1 drop per second when held upside down, clean the nipple better or enlarge the hole.
Nappies
  • Avoid tight nappies and clothing around the tummy.
Pacifiers ('dummies')
  • Constant sucking on a pacifier can pump the stomach up with swallowed air.
Smoking
  • Avoid exposure to tobacco smoke (second-hand smoke).

When to use feed thickeners and other medication

If you have tried the above and nothing seems to be working, talk to your lead maternity carer, local Plunket nurse or your doctor. They may be able to suggest other strategies and will be able to discuss the use of feed thickeners and other medication to reduce the spilling, if it is accompanied by unsettled times.

Feed thickeners or thickened feeding formulas 
  • These may reduce the amount that is spilt but do not always reduce how often the spilling or other symptoms happen.
  • It can be an expensive option.
Antacids 
  • A trial of an antacid (alginates) for babies (such as Gaviscon Infant®) may be considered, for a short time. However, evidence for its use and safety is inconsistent.
    • For breastfed babies, mix with a small amount of breast milk into a thick paste and give on feeding spoon part way through feed (while baby is still hungry enough to take it from a spoon).
    • For formula fed babies mix it into bottle of formula.
  • Due to constipation, babies can often only tolerate 1 sachet, four times daily.
Omeprazole

For the small number of infants that do have GOR, medicine such as omeprazole may sometimes be used to treat it. This is usually under specialist recommendation. However, be aware that:

  • There is lack of evidence to show that omeprazole reduces irritability, crying, and fussing.
  • In New Zealand, omeprazole is not approved for use in infants under 1 year old.
  • There are concerns around the safety of omeprazole in infants. It is possible that infants prescribed omeprazole may have increased risk of pneumonia and gastroenteritis (chest and stomach infections).
  • If omeprazole is used, it should be tried for a short period (about 4 weeks). If the baby is still irritable after this time, then the medicine should be stopped.

Be prepared for spills – some practical tips

If you are looking after a baby who's constantly bringing up feeds, you may feel that you always smell of sour milk. Being prepared can help you manage the situation:

  • Place a towel or flannel over your shoulder, when you are carrying your baby upright.
  • Dress your baby in vests and sleepsuits, as they're easy to wash. 
  • Pick a special sofa or chair for when you're sitting with your baby, and cover it with a throw or sheet. Have a spare cover so you can wash one while using another.
  • Use a washable cover on your baby's car seat or pushchair, and again, have a spare so you can wash one and use one.
  • Pack extra sets of clothes for you and your baby, should you need it. Also carry a a bag for soiled clothing.

Support

If you are coping with a baby who cries constantly and won't sleep, it's easy to feel overcome and exhausted. It can be helpful to get support for yourself and talk to others about managing your baby’s reflux from day to day.

Crying over spilt milk Phone 0800 380 517. Gastric Reflux Support Network New Zealand.
Spilt milk For parents who are coping with infants who spill but do not meet the criteria for gastric reflux.
Plunket 0800 933 922. New Zealand's largest provider of support services for the development, health and wellbeing of children under 5. 

Learn more

Irritable infants reflux and GORD BPAC NZ, 2011
Infant acid reflux – basic symptoms
 Mayo Clinic – Mayo Foundation for Medical Education and Research, USA, 2013
What is gastric reflux? Crying Over Spilt Milk, Gastric Reflux Support Network New Zealand for Parents & Infants Charitable Trust, 2015

Credits: Health Navigator Team. Last reviewed: 22 Mar 2016