- Caring for Kids With GERD
- Eating, Diet, & Nutrition for GER & GERD in Children & Teens
- How can diet help prevent or relieve GER or GERD in children and teens?
- What should a child or teen with GERD avoid eating or drinking?
- What can a child or teen eat if they have GERD?
- Gastroesophageal Reflux
- Caring for children with heartburn, reflux and gastroesophageal reflux disease
- Our approach to heartburn, reflux and GERD
- Heartburn, reflux and GERD services we offer
- Diagnosing and treating heartburn, reflux and GERD
- How To Help Your Child Manage Their Acid Reflux
- Pediatric GERD
- Reducing the Symptoms of Acid Reflux and Pediatric GERD
- Infants with Acid Reflux
- Causes of Acid Reflux in Infants
- Immature Lower Esophageal Sphincter
- Short or Narrow Esophagus
- Gastroparesis (Delayed Emptying of the Stomach)
- Hiatal Hernia
- Angle of His
- When to Call Your Child’s Doctor
- My baby spits up – is this a problem?
- Some causes of excessive spitting up
- My older baby just started spitting up more – what’s up?
- Gastroesophageal Reflux Disease (GERD)
- Breastfeeding Tips
- What can I do to minimize spitting up/reflux?
- Additional Information
- A Diet for Breastfeeding Moms of Babies with Acid Reflux
- Significance of Your Diet
- Making Changes
- Effects of Acid Relux
- Identifying Causes
- Elimination Diet
Caring for Kids With GERD
Caring for a baby or child with chronic acid reflux or gastroesophageal reflux disease (GERD) can be challenging. GERD causes food and stomach acid to reflux or flow up into the esophagus — the muscular tube that connects the mouth and stomach — after your child eats. Understandably, babies and children with GERD can become fussy and irritable. They may not sleep well and may also be reluctant to eat.
GERD symptoms include frequent spitting up or vomiting, nausea, coughing, trouble swallowing, breathing problems, poor appetite, and difficulty gaining weight. Untreated GERD can lead to laryngitis and even pneumonia since acid and food particles can irritate the vocal cords and the lungs.
Fortunately, there are there are ways to reduce the severity of your child’s reflux even without medication.
Tips for Children With GERD
After discussing your child’s symptoms with a pediatrician, try these easy changes in diet and lifestyle to help ease your child’s GERD:
- To help reduce the likelihood of reflux, try feeding your baby a smaller quantity of breast milk or formula, but more frequently than usual.
- If your baby is bottle-fed, ask your doctor whether you can include a little rice cereal in the bottle. This may thicken the contents enough so they don’t reflux as easily.
- It’s possible that your baby’s reflux symptoms are actually due to a sensitivity to soy protein, wheat, or another ingredient in the formula or cereal. Be sure to read ingredient labels closely and talk to your pediatrician about whether a particular food sensitivity may be to blame.
- Burp your baby often during and after feedings to minimize excess gas and added pressure on the stomach.
- To discourage reflux after meals, hold your baby vertically following feedings or keep her seated in a completely upright position.
- Don’t put your baby in the car seat when you’re not on the road since this position can promote reflux.
- If you have an older child with GERD, serve smaller meals more often to help stave off reflux.
- Remind your child to not to lie down within two hours of eating.
- Let your child know that wearing tight belts and bending over can worsen reflux symptoms.
- Be sure your baby’s diapers, or your child’s waistbands and belts, aren’t too tight.
- If your child is overweight, talk to your pediatrician about safe ways to lose weight.
- No baby or child should be around cigarette smoke, but it’s even more important when the child has GERD, since smoke can make reflux symptoms even worse.
In some cases, it may also help to raise the head of your child’s bed by 30 degrees (about 6 to 8 inches). Pillows alone won’t do the trick, so you will need to devise a safe way to elevate the bed, such as by securing blocks of wood or concrete underneath the bedposts.
However, do not elevate your baby or toddler’s bed without first speaking to your pediatrician, since younger children can actually slide down their mattress if not positioned correctly. Additionally, do not use pillows to prop up babies or toddlers, since they can block the airway and lead to suffocation.
Planning Meals for Children With GERD
Certain foods may aggravate GERD and should be avoided, including:
- Carbonated drinks
- Fatty foods such as french fries or pizza
- Spicy foods
- Acidic food, such as pickles, citrus fruit and juices, and ketchup or other tomato-based foods
- Caffeine, for instance in soda
- Mustard and vinegar
Some foods may cause more reflux symptoms than others, so keep track of your child’s intake for a few days to identify specific food triggers. Also keep in mind that children with GERD shouldn’t have any food in the two to three hours before bedtime.
It may take a little trial and error to see what works best to decrease your baby or child’s GERD. If your child’s symptoms do persist, talk to your pediatrician about other treatment options, including medication. Rest assured though — GERD can be effectively managed.
Eating, Diet, & Nutrition for GER & GERD in Children & Teens
How can diet help prevent or relieve GER or GERD in children and teens?
You can help a child or teen prevent or relieve their symptoms from gastroesophageal reflux (GER) or gastroesophageal reflux disease (GERD) by changing their diet. He or she may need to avoid certain foods and drinks that make his or her symptoms worse. Other dietary changes that can help reduce the child or teen’s symptoms include
- decreasing fatty foods
- eating small, frequent meals instead of three large meals
What should a child or teen with GERD avoid eating or drinking?
He or she should avoid eating or drinking the following items that may make GER or GERD worse
- greasy or spicy foods
- tomatoes and tomato products
What can a child or teen eat if they have GERD?
Eating healthy and balanced amounts of different types of foods is good for your child or teen’s overall health. For more information about eating a balanced diet, visit Choose My Plate.
If your child or teen is overweight or obese, talk with a doctor or dietitian about dietary changes that can help with losing weight and decreasing the GERD symptoms.
The information provided on Crying Over Spilt Milk is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician.
Please seek assistance from your Doctor, Midwife, Well Child Provider, Health Professional or Dietician about feeding your baby.
The foods that can make reflux pain worse for a baby/child are:
- Fruit and fruit juice, especially oranges, apples and bananas. Pears are the least acidic and an ideal first fruit for reflux babies.
- Tomatoes and tomato sauce
- Tea and coffee
- Spicy Foods
- Fizzy drinks (especially coke)
- Fatty foods (i.e. fish and chips!!)
It is important to note however, that these foods will not worsen vomiting, and so it is not necessary to avoid them in a ‘happy chucker’.
Well tolerated first solids include baby rice (please check the ingredients as some brands of rice cereals, contain milk products), kumara and pumpkin. Here is a Feeding Guideline that provides a sensible plan for introducing solids to a baby with reflux if the foods listed on this page that are likely to cause problems are introduced later and with caution: Starting Solids from heathed.govt.nz
Breastfeeding and the mother’s diet
Citrus fruit, tomatoes, caffeine containing drinks (tea, coffee, coke) and chocolate may also need to be avoided by the breast-feeding mother of a reflux baby. Of course alcohol should also be avoided by the breast-feeding mother. Some asthma medication (e.g. Theophylline) taken by the breast-feeding mother may also make the baby worse. Remember that all babies are different and different babies react to different foods – the list above is a guideline only.
Volume and variety
The introduction of solids is known to either help reflux or make it worse when introduced.
Some babies progress well onto solids, but are reluctant to take mixed (lumpy) textures. Aim to start your baby on mixed (lumpy) textured solids by seven to nine months of age. Delaying introduction of mixed textures until beyond nine months is associated with fussier feeding during pre-school years. Make eating a fun experience and allow your child opportunities to feed themselves and experience new textures in their own way. Be prepared for lots of mess! Research shows it is the frequency of tasting solids rather than the amount your child eats that helps them progress onto new tastes and textures. Therefore, try offering your seven to nine month baby very small amounts of mixed texture food at least twice daily until your child indicates he/she is keen to eat more.
Food allergy or intolerance
Studies have shown that about one third of infants with gastric reflux disease will have a cow’s milk protein allergy or intolerance. Skin prick or blood tests may not diagnose an allergy as gastrointestinal delayed reactions are often intolerances.
If you suspect that this is a problem for your baby and you are bottle-feeding, you may need to try an alternative to standard cow’s milk based formula. (Please discuss which formula to choose with your Health Professional (Doctor, Well Child Provider or Dietician) or phone Nutricia on 0800 258 268 to speak to a Dietician).) If you are breast-feeding, you can go on a “dairy-free” diet. This means avoiding all milk and foods that have dairy products in them (e.g. cheese, yoghurt, bread, biscuits, cakes etc.) for up to two or three weeks to see if there is any improvement in your baby. Any solids that your baby is eating will need to be dairy free also.
For information on preventing food allergy please speak to your health professional. You may also find useful information at http://www.allergy.org.nz/
Some parents have found that unproven forms of testing such as Kinesiology have helped them to remove offending foods. GRSNNZ doesn’t endorse these and would recommend that limited diets also be supervised by a dietician, that a medically qualified health professional (paediatrician, allergist, immunologist etc.) be involved and if appropriate the foods be challenged after a suitable time lapse.
Cow’s milk protein allergy should not be confused with lactose intolerance. Breast milk always contains lactose even if the mother is on a strict dairy free, lactose free diet so a baby who responds to a change in their mother’s diet, does not have a lactose intolerance.
© Gastric Reflux Association for the Support of Parents/babies (GRASP) and Crying Over Spilt Milk Gastric Reflux Support Network New Zealand for Parents of Infants and Children Charitable Trust (GRSNNZ) 2004. Used, edited and added to by Roslyn Ballantyne (RN), National Coordinator GRSNNZ and Fiona Kenworthy, Speech-Language Therapist with permission. Last updated by Roslyn Ballantyne, 13/11/2019.
Page may be printed or reproduced for personal use of families, as long as copyright and Crying Over Spilt Milk‘s URL are included. It may not be copied to other websites or publications without permission and acknowledgement. This information (unedited) was also provided (by GRASP) to health professionals in New Zealand to use ” to continue to support and inform families with babies/children with Gastro-oesophageal Reflux.”
Page last updated 13th November, 2019
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At one time or another, many adults have had heartburn (an uncomfortable feeling in the chest) after eating a big meal or spicy foods.
When these symptoms happen often or aren’t tied to certain ingredients, they might be due to gastroesophageal reflux (GER), also called reflux.
But GER isn’t just a problem for adults — kids can have it, too, even babies. In infants, it can cause vomiting and fussiness after feeding. And in older kids and teens, GER can lead to heartburn, and stomach and chest discomfort.
Most kids outgrow GER over time but some will need medical treatment. Reflux that causes problems like poor growth, vomiting, or damage to the esophagus is called GERD (gastroesophageal reflux disease). GERD is more serious than GER and is usually treated with medicine.
The burping, heartburn, and spitting up associated with GER are the result of acidic stomach contents moving backward into the esophagus. This can happen because the muscle that connects the esophagus to the stomach (the esophageal sphincter) relaxes at the wrong time or doesn’t properly close.
Many people have reflux regularly and it’s not usually a cause for concern. But with GER, reflux happens more often and causes noticeable discomfort. After nearly all meals, GER causes heartburn (also known as acid indigestion), which feels like a burning sensation in the chest, neck, and throat.
In babies with GER, breast milk or formula regularly refluxes into the esophagus, and sometimes out of the mouth. Sometimes babies regurgitate forcefully or have “wet burps.” Most babies outgrow GER between the time they are 1 or 2 years old.
But in some cases, GER symptoms last. Kids with developmental or neurological conditions, such as cerebral palsy, are more at risk for GER and can have more severe, lasting symptoms.
Symptoms of GER
Heartburn is the most common symptom of GER in kids and teens. It can last up to 2 hours and tends to be worse after meals. In babies and young children, GER can lead to problems during and after feeding, including:
- frequent regurgitation or vomiting, especially after meals
- choking or wheezing (if the contents of the reflux get into the windpipe and lungs)
- wet burps or wet hiccups
- spitting up that continues beyond a child’s first birthday (when it stops for most babies)
- irritability or inconsolable crying after eating
- refusing to eat or eating only small amounts
- failure to gain weight
Some of these symptoms may become worse if a baby lies down or is placed in a car seat after a meal.
Complications of GER
Some children develop complications from GER. The constant reflux of stomach acid can lead to:
- breathing problems (if the stomach contents enter the trachea, lungs, or nose)
- redness and irritation in the esophagus, a condition called esophagitis
- bleeding in the esophagus
- scar tissue in the esophagus, which can make swallowing difficult
Because these complications can make eating painful, GER can interfere with proper nutrition. So if your child isn’t gaining weight as expected or is losing weight, it’s important to talk with your doctor.
In older kids, doctors usually diagnose reflux by doing a physical exam and hearing about the symptoms. Try to keep track of the foods that seem to bring on symptoms in your child — this information can help the doctor determine what’s causing the problem.
In younger children and babies, doctors might run these tests to diagnose GER or rule out other problems:
- Barium swallow. This is a special X-ray that can show the refluxing of liquid into the esophagus, any irritation in the esophagus, and abnormalities in the upper digestive tract. For the test, your child must swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process.
- 24-hour impedance-probe study. This is considered the most accurate way to detect reflux and the number of reflux episodes. A thin, flexible tube is placed through the nose into the esophagus. The tip rests just above the esophageal sphincter to monitor the acid levels in the esophagus and to detect any reflux.
- Milk scans. This series of X-ray scans tracks a special liquid as a child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs.
- Upper endoscopy. In this test, doctors directly look at the esophagus, stomach, and a portion of the small intestines using a tiny fiber-optic camera. During the procedure, doctors also may biopsy (take a small sample of) the lining of the esophagus to rule out other problems and see whether GER is causing other complications.
Treatment for GER depends on the type and severity of the symptoms.
In babies, doctors sometimes suggest thickening the formula or breast milk with up to 1 tablespoon of oat cereal to reduce reflux. Making sure the baby is in a vertical position (seated or held upright) during feedings can also help.
Older kids often get relief by avoiding foods and drinks that seem to trigger GER symptoms, including:
- citrus fruits
- food and drinks with caffeine
- fatty and fried foods
- garlic and onions
- spicy foods
- tomato-based foods and sauces
Doctors may recommend raising the head of a child’s bed 6 to 8 inches to minimize reflux that happens at night. They also may try to address other conditions that can contribute to GER symptoms, including obesity and certain medicines — and in teens, smoking and alcohol use.
If these measures don’t help relieve the symptoms, the doctor may also prescribe medicine, such as H2 blockers, which can help block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces.
Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter muscle work better and the stomach empty faster.
In rare cases, when medical treatment alone doesn’t help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option. This involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus.
When to Call the Doctor
If your child has GER symptoms, talk with your doctor. With proper diagnosis and treatment, kids can get relief and avoid longer-term health problems.
Reviewed by: J. Fernando del Rosario, MD Date reviewed: January 2015
Caring for children with heartburn, reflux and gastroesophageal reflux disease
Learn how our Gastroenterology, Liver and Nutrition Program cares for children with heartburn, reflux and gastroesophageal reflux disease (GERD).
- What is heartburn and reflux and GERD?
Related tests and treatments:
- Upper GI series
- 24-hour pH-impedance probe
- Esophageal manometry
- Gastric emptying study
Our approach to heartburn, reflux and GERD
For more than two decades, the Constipation and Reflux Program at Children’s Hospital of Wisconsin has treated thousands of children with heartburn and reflux. Run by experienced pediatric nurse practitioners, the program specializes in treating babies 18 months and younger who do not have feeding issues. Older children and children who have feeding issues are usually treated by our pediatric gastroenterologists and multidisciplinary feeding team, who are experts in gastroesophageal reflux disease and other diagnoses that cause feeding problems.
We believe in taking an evidence-based and noninvasive approach whenever possible. Sometimes the infants referred to our program are already on reflux medications, and we will wean them off if we feel the medication is unnecessary. We often try diet and lifestyle changes before prescribing medications to minimize your child’s risks and side effects. We use a combination of education, behavior management and medication interventions tailored to meet the unique needs of your child.
Heartburn, reflux and GERD services we offer
Our experts can help in many ways. The services we offer include:
- Diagnosis and evaluation
- Customized treatment plan
- Nutritional counseling
Diagnosing and treating heartburn, reflux and GERD
During your first clinic visit, your GI provider will obtain a health history, perform a physical exam and develop a customized treatment plan with your family. The health history could indicate a trigger for your child’s heartburn and reflux, such as medications that irritate the stomach’s lining or certain foods. If your child’s provider suspects GERD or another GI condition, he or she might recommend one or more of the following tests:
- Upper GI series
- 24-hour pH-impedance probe
- Esophageal manometry
- Gastric emptying study
Reflux is so common in infants that testing and treatment usually isn’t warranted, though your doctor or nurse practitioner may suggest eliminating dairy or soy in formula or breast milk to see if that improves your baby’s symptoms. Diet and lifestyle changes can also be helpful in managing heartburn and reflux in older children.
If your child has gastroesophageal reflux disease your doctor might prescribe a medication (such as a H2 blocker or proton-pump inhibitor) to decrease the amount of stomach acid. Medications are typically stopped after two months. At that point, the esophagus is usually healed, which alleviates the discomfort of heartburn and reflux.
How To Help Your Child Manage Their Acid Reflux
Nothing is worse for a parent than to watch their child hurting or unhappy and not know why. It is believed that approximately 10% of all children suffer from the uncomfortable symptoms of acid reflux, and depending on their age, they may not even be able to tell you what’s bothering them.
Help put your mind at ease by brushing up on these common signs and symptoms of acid reflux in both babies and young children.
In order for our food to get from our mouth to our stomach, it must travel down the esophagus. At the base of the esophagus there is a small valve that constricts to prevent our food from coming back up. Sometimes this valve can be weakened, allowing food and acid to return up the esophagus and into the mouth. This is known as gastroesophageal reflux (GER) or gastroesophageal reflux disease (GERD).
When GERD occurs, it is incredibly uncomfortable and will leave a sour taste in your child’s mouth. They may cry after eating or not want to eat at all. It is also common for children to have a frequent sore throat or cough for no apparent reason, and they may belch more than normal. Infants may spit up often and cry, especially if they are put into a reclining position.
Reducing the Symptoms of Acid Reflux and Pediatric GERD
If a parent suspects their child may have acid reflux, there are several dietary and lifestyle changes that can be made to help manage these painful symptoms and make your child more comfortable.
One of the best ways to begin treating your child’s acid reflux is to feed them smaller meals with less fat content. Other tips include the following:
- Avoid serving spicy foods.
- Reduce the amount of juices and acidic foods in their diet.
- Help reduce the amount of calories your child eats each day if they are overweight, as obesity is one of the biggest contributors to pediatric GERD.
- Make a rule that there will be no eating 3 – 4 hours before bedtime since lying down makes the symptoms worse.
- Find a way to lift their head up by 6 – 8 inches while they sleep.
- Avoid chocolate, tomato sauces, and peppermint.
- Monitor what foods cause their discomfort and be able to convey that to a Meridian Pediatrics for a proper diagnosis.
Infants with Acid Reflux
Infants are among the most likely to experience acid reflux, so knowing the symptoms and how to treat them is essential for a happy baby. Most infants with this condition will improve by about 6 months of age as they start to spend more of their time upright.
Parents can improve their infant’s acid reflux by following these tips:
- Burp your infant during and after feeding to manage gas.
- After eating hold your infant upright.
- Avoid using a carseat when you are not traveling as this position can make symptoms worse.
- If your child spits up frequently, try feeding them a smaller amount of breastmilk or formula with each feeding.
- Loosen diapers so they are not too tight.
- Try feeding your baby rice cereal with milk. The ticker substance will make it less likely to come back up.
- Don’t allow smoking around your infant as this can cause symptoms of acid reflux as well as several other serious health conditions.
If your child’s acid reflux symptoms become worse or do not improve with lifestyle and dietary changes then it is probably time to consider seeing us. To schedule an appointment with Meridian Pediatrics, please call our local office today at (208) 338-5437.
Causes of Acid Reflux in Infants
Acid reflux occurs when the contents of the stomach are refluxed into the esophagus. It’s very common in infants and most often happens after a feeding. Although the exact cause is unknown, there are several factors that can contribute to acid reflux.
Immature Lower Esophageal Sphincter
The lower esophageal sphincter (LES) is a ring of muscle at the bottom of the esophagus that opens to allow food into the stomach and closes to keep it there. This muscle isn’t fully matured in infants. When the LES opens, the contents of the stomach can flow back into the esophagus, causing the infant to spit up or vomit.
This is very common and does not usually cause other symptoms. However, constant regurgitation from acid reflux can sometimes cause damage to the esophageal lining. This is much less common. If it causes symptoms such as poor weight gain, it may then be called gastroesophageal reflux disease, or GERD.
Short or Narrow Esophagus
Refluxed stomach contents have a shorter distance to travel if the esophagus is shorter than normal. And if the esophagus is narrower than normal, the lining might more easily become irritated.
Changing the foods your infant eats may help reduce the chances of acid reflux. And if you breast-feed, making changes to your diet might help your infant.
Certain foods may be causing acid reflux, depending on your infant’s age. For example, citrus fruits and tomato products increase acid production in the stomach. Foods like chocolate, peppermint, and high-fat foods can keep the LES open longer, causing the contents of the stomach to reflux.
Gastroparesis (Delayed Emptying of the Stomach)
Gastroparesis is a disorder that causes the stomach to take too long to empty. The stomach normally contracts to move food down into the small intestine for digestion. However, stomach muscles don’t work properly if there is damage to the vagus nerve because this nerve controls the movement of food from the stomach through the digestive tract. In gastroparesis, the stomach contents remain in the stomach longer than they’re supposed to, encouraging reflux. It’s rare in healthy infants.
A hiatal hernia is a condition in which part of the stomach sticks through an opening in the diaphragm. A small hiatal hernia doesn’t cause problems, but a larger one can cause acid reflux and heartburn.
Hiatal hernias are very common, especially in people over the age of 50, but they are rare in infants. However, the causes are unknown. A hiatal hernia in children is usually congenital (present at birth) and may cause gastric acid to reflux from the stomach into the esophagus.
Positioning — especially during and after feeding — is a frequently overlooked cause of acid reflux in infants. A horizontal position makes it easier for the stomach contents to reflux into the esophagus. Simply keeping your infant in an upright position while you’re feeding them and for 20 to 30 minutes afterward may reduce acid reflux.
This also applies to sleeping positions. It’s recommended that babies sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS). However, babies who experience reflux may benefit from sleeping in a slightly elevated position on their left sides. This position may make it harder for the stomach contents to reflux. However, the risk of SIDS is doubled for infants sleeping on their side versus their back. Discuss the potential pros and cons with your doctor before placing your infant to sleep in any position other than on their back.
Angle of His
The angle at which the base of the esophagus joins the stomach is known as the “angle of His,” and differences in this angle may contribute to acid reflux. This angle most likely affects the ability of the LES to keep the contents of the stomach from refluxing. If the angle is too sharp or too steep, it may make it difficult to keep the stomach contents down.
Feeding your infant too much at once, either with a bottle or while breast-feeding, can cause acid reflux. Feeding your infant too frequently can also cause acid reflux. An oversupply of food can put too much pressure on the LES, which will cause your infant to spit up. That unnecessary pressure is taken off the LES and reflux decreases when you feed your infant less food more often. However, if your baby spits up often, but is otherwise happy and growing well, you may not need to change your feeding routine at all. Talk with your doctor if you have concerns that you are overfeeding your baby.
When to Call Your Child’s Doctor
Your infant will usually grow out of acid reflux. However, call your child’s doctor immediately if you notice that your child:
- isn’t gaining weight
- is projectile vomiting
- has blood in their stool
- won’t eat
While it isn’t easy to determine the exact cause of acid reflux in infants, lifestyle and diet changes may help eliminate some of the factors. If the acid reflux doesn’t go away with these changes and your baby has other symptoms, a doctor may have to perform tests to rule out a gastrointestinal obstruction or other problems with the esophagus.
By Kelly Bonyata, BS, IBCLC
© Paul Hakimata – Fotolia.com
My baby spits up – is this a problem?
Spitting up, sometimes called physiological or uncomplicated reflux, is common in babies and is usually (but not always) normal. Most young babies spit up sometimes, since their digestive systems are immature, making it easier for the stomach contents to flow back up into the esophagus (the tube connecting mouth to stomach).
Babies often spit up when they get too much milk too fast. This may happen when baby feeds very quickly or aggressively, or when mom’s breasts are overfull. The amount of spitup typically appears to be much more than it really is. If baby is very distractible (pulling off the breast to look around) or fussy at the breast, he may swallow air and spit up more often. Some babies spit up more when they are teething, starting to crawl, or starting solid foods.
A few statistics (for all babies, not just breastfed babies):
- Spitting up usually occurs right after baby eats, but it may also occur 1-2 hours after a feeding.
- Half of all 0-3 month old babies spit up at least once per day.
- Spitting up usually peaks at 2-4 months.
- Many babies outgrow spitting up by 7-8 months.
- Most babies have stopped spitting up by 12 months.
If your baby is a ‘Happy Spitter’ –gaining weight well, spitting up without discomfort and content most of the time — spitting up is a laundry & social problem rather than a medical issue.
Some causes of excessive spitting up
- Breastmilk oversupply or forceful let-down (milk ejection reflex) can cause reflux-like symptoms, and usually can be remedied with simple measures.
- Food sensitivities can cause excessive spitting. The most likely offender is cow’s milk products (in baby’s or mom’s diet). Other things to ask yourself: is baby getting anything other than breastmilk – formula, solids (including cereal), vitamins (fluoride, iron, etc.), medications, herbal preparations? Is mom taking any medications, herbs, vitamins, iron, etc.?
- Babies with Gastroesophageal Reflux Disease (GERD) usually spit up a lot (see below).
- Although seldom seen in breastfed babies, regular projectile vomiting in a newborn can be a sign of pyloric stenosis, a stomach problem requiring surgery. It occurs 4 times more often in boys than in girls, and symptoms usually appear between 3 and 5 weeks of age. Newborns who projectile vomit at least once a day should be checked out by their doctor.
My older baby just started spitting up more – what’s up?
Some older babies will start spitting up more after a period of time with little or no spitting up. It’s not unusual to hear of this happening around 6 months, though you also see it at other ages. If the spitting up is very frequent (particularly if baby does not seem well), consider the possibility of a GI illness.
If baby does not seem ill, then here are some possible causes:
- It’s unlikely that your baby has suddenly developed a sensitivity to something in your milk, unless there’s something really new in your diet or you’re eaten LOTS of a particular food very recently. Any foods that baby eats are more likely than mom’s foods to cause the spitting up. Has baby started solids recently or tried a new food? Are you or baby taking any new medications? Have you or baby started taking vitamins or changed your vitamins?
- Has baby been fussier than normal, and/or crying more lately? If so, he is probably swallowing more air than usual, which can cause the spitting up.
- Spitting up can be caused by teething. When teething, babies tend to drool more and often swallow a lot of that extra saliva – this can cause extra spitting up.
- A cold or allergies can result in baby swallowing mucus and spitting up more.
- Baby may be hitting a growth spurt and swallowing more air when he nurses, especially if he’s been “guzzling” lately.
- If you tend to have oversupply or a fast let-down, some moms see renewed symptoms (which can include spitting up) after a growth spurt.
Essentially, though, if your baby is healthy and doing well despite the spitting up — gaining well, having enough wet/dirty diapers — then this is a laundry problem rather than a medical issue.
Gastroesophageal Reflux Disease (GERD)
A small percentage of babies experience discomfort and other complications due to reflux – this is called Gastroesophageal Reflux Disease. These babies have been termed by some as ‘Scrawny Screamers’ (as compared to the Happy Spitters). There seems to be a family tendency toward reflux. GERD is particularly common in preemies (due to their immaturity) and in babies with other health problems. GERD usually improves by 12-24 months.
Following are symptoms of GERD — there are varying degrees and need your doctor’s involvement to diagnose:
- Frequent spitting up or vomiting; discomfort when spitting up. Some babies with GERD do not spit up – silent reflux occurs when the stomach contents only go as far as the esophagus and are then re-swallowed, causing pain but no spitting up.
- Gagging, choking, frequent burping or hiccoughing, bad breath.
- Baby may be fussy and sleep less due to discomfort.
Warning signs of severe reflux:
- Inconsolable or severe fussiness or crying associated with feedings.
- Poor weight gain, weight loss, or failure to thrive. Difficulty eating. Breast/food refusal.
- Difficulty swallowing, sore throat, hoarseness, chronic nasal/sinus congestion, chronic sinus/ear infections.
- Spitting up blood or green/yellow fluid.
- Sandifer’s syndrome: Baby may ‘posture’ and arch the neck & back to relieve reflux pain–this lengthens the esophagus and reduces discomfort.
- Breathing problems: bronchitis, wheezing, chronic cough, pneumonia, asthma, aspiration, apnea, cyanosis.
GERD may cause babies to either undereat (if they associate feeding with the after-feeding pain, or if it hurts to swallow) or overeat (because sucking keeps the stomach contents down in the stomach and because mother’s milk is a natural antacid).
Current information on reflux indicates that testing or treatment for reflux in babies younger than 12 months should be considered only if spitting up is accompanied by poor weight gain or weight loss, severe choking, lung disease or other complications. Per Donna Secker, MS, RD in the article Gastroesophageal Reflux Disease, “The infant with significant reflux who seems to be growing well and has no other significant health problems benefits most from little or no therapy.”
When GERD is suspected, many doctors first try a trial of various reflux medications (without running tests), to see if the medications improve baby’s symptoms. If testing is done, a 24-hour pH probe study () is the current “gold standard” for reflux testing in babies; this is a procedure where a tube is placed down baby’s throat to measure the acid level at the bottom of the esophagus. A barium swallow (upper GI) is not so invasive (baby swallows a barium mixture, then an x-ray is taken) but is not really effective for diagnosing reflux in babies, since most babies will reflux when given barium. An upper GI will not identify whether baby’s stomach contents are higher in acid or if there has been any esophagus damage due to reflux, but it will show if there are any blockages or narrowing of the stomach valves that may be causing or aggravating the reflux. Additional tests may be recommended in certain circumstances (see the links below for additional information). In rare cases, when baby has very severe reflux that is not relieved by medication, surgery may be recommended.
- Aim for frequent breastfeeding, whenever baby cues to feed. These smaller, more frequent feedings can be easier to digest.
- Try positioning baby in a semi-upright or sitting position when breastfeeding, or recline back so that baby is above and tummy-to-tummy with mom. See this information on upright nursing positions.
- For fussy, reluctant feeders, try lots of skin to skin contact, breastfeeding in motion (rocking, walking), in the bath or when baby is sleepy.
- Ensure good latch to minimize air swallowing.
- Allow baby to completely finish one breast (by waiting until baby pulls off or goes to sleep) before you offer the other. Don’t interrupt active suckling just to switch sides. Switching sides too soon or too often can cause excessive spitting up (see Too Much Milk?). For babies who want to breastfeed very frequently, try switching sides every few hours instead of at every feed.
- Encourage non-nutritive/comfort sucking at the breast, since non-nutritive sucking reduces irritation and speeds gastric emptying.
- Avoid rough or fast movement or unnecessary jostling or handling of your baby right after feeding. Baby may be more comfortable when help upright much of the time. It is often helpful to burp often.
- As always, watch your baby and follow his cues to determine what works best to ease the reflux symptoms.
What can I do to minimize spitting up/reflux?
- Breastfeed! Reflux is less common in breastfed babies. In addition, breastfed babies with reflux have been shown to have shorter and fewer reflux episodes and less severe reflux at night than formula-fed babies . Breastfeeding is also best for babies with reflux because breastmilk leaves the stomach much faster (so there’s less time for it to back up into the esophagus) and is probably less irritating when it does come back up.
- The more relaxed your infant is, the less the reflux.
- Eliminate all environmental tobacco smoke exposure, as this is a significant contributing factor to reflux.
- Reduce or eliminate caffeine. Excessive caffeine in mom’s diet can contribute to reflux.
- Allergy should be suspected in all infant reflux cases. According to a review article in Pediatrics , up to half of all GERD cases in babies under a year are associated with cow’s milk protein allergy. The authors note that symptoms can be similar and recommend that pediatricians screen all babies with GERD for cow’s milk allergy. Allergic babies generally have other symptoms in addition to spitting up.
- Reflux is worst when baby lies flat on his back.
- Many parents have found that carrying baby in a sling or other baby carrier can be helpful.
- Avoid compressing baby’s abdomen – this can increase reflux and discomfort. Dress baby in loose clothing with loose diaper waistbands; avoid “slumped over” or bent positions; for example, roll baby on his side rather than lifting legs toward tummy for diaper changes.
- Recent research has compared various positions to determine which is best for babies with reflux. Elevating baby’s head did not make a significant difference in these studies , although many moms have found that baby is more comfortable when in an upright position. The positions shown to significantly reduce reflux include lying on the left side and prone (baby on his tummy). Placing the infant in a prone position should only be done when the child is awake and can be continuously monitored. Prone positioning during sleep is almost never recommended due to the increased SIDS risk.
- Although recent research does not support recommendations to keep baby in a semi-upright position (30° elevation), this remains a common recommendation. Positioning at a 60° elevation in an infant seat or swing has been found to increase reflux compared with the prone (tummy down) position .
- As always, experiment to find what works best for your baby.
- If your child is taking reflux medications, keep in mind that dosages generally need to be monitored and adjusted frequently as baby grows.
What about thickened feeds?
Baby cereal, added to thicken breastmilk or formula, has been used as a treatment for GER for many years, but its use is controversial.
Does it work? Thickened feeds can reduce spitting up, but studies have not shown a decrease in reflux index scores (i.e., the “silent reflux” is still present). Per Donna Secker, MS, RD in Gastroesophageal Reflux Disease, “The effect of thickened feedings may be more cosmetic (decreased regurgitation and increased postprandial sleeping) than beneficial.” Thickened feeds have been associated with increased coughing after feedings, and may also decrease gastric emptying time and increase reflux episodes and aspiration. Note that rice cereal will not effectively thicken breastmilk due to the amylase (an enzyme that digests carbohydrates) naturally present in the breastmilk.
Is it healthy for baby? If you do thicken feeds, monitor baby’s intake since baby may take in less milk overall and thus decrease overall nutrient intake. There are a number of reasons to avoid introducing cereal and other solids early. There is evidence that the introduction of rice or gluten-containing cereals before 3 months of age increases baby’s risk for type I diabetes. In addition, babies with GERD are more likely to need all their defenses against allergies, respiratory infections and ear infections – but studies show that early introduction of solids increases baby’s risk for all of these conditions.
The breastfeeding relationship: Early introduction of solids is associated with early weaning. Babies with reflux are already at greater risk for fussy nursing behavior, nursing strikes or premature weaning if baby associates reflux discomfort with breastfeeding.
Safety issues: Never add cereal to a bottle without medical supervision if your baby has a weak suck or uncoordinated sucking skills.
Spitting Up: Is it Reflux? by Anne Smith, IBCLC
LLL FAQ on breastfeeding and reflux
Gastroesophageal Reflux in Young Children by Pamela Tyler, M.S., CCC SLP
The Children’s Digestive Health and Nutrition Foundation (CDHNF)
North American Society for Pediatric Gastroenterology and Nutrition (NASPGHAN)
Bailey DJ, Andres JM, Danek GD, Pineiro-Carrero VM. Lack of efficacy of thickened feeding as treatment for gastroesophageal reflux. J Pediatr 1987 Feb;110(2):187-9.
Carroll AE, Garrison MM, Christakis DA. A Systematic Review of Nonpharmacological and Nonsurgical Therapies for Gastroesophageal Reflux in Infants. Arch Pediatr Adolesc Med. 2002;156:109-113.
Craig WR, Hanlon-Dearman A, Sinclair C, Taback S, Moffatt M. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003502.
Ewer AK, Durbin GM, Morgan ME, Booth IW. Gastric emptying in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1994 Jul;71(1):F24-7. “On average, expressed breast milk emptied twice as fast as formula milk.”
Heacock HJ, Jeffery HE, Baker JL, Page M. Influence of breast versus formula milk on physiological gastroesophageal reflux in healthy, newborn infants. J Pediatr Gastroenterol Nutr. 1992 Jan;14(1):41-6.
Iacono G, et al. Gastroesophageal reflux and cow’s milk allergy in infants: a prospective study. J Allergy Clin Immunol. 1996 Mar;97(3):822-7.
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med 1997 Jun;151(6):569-72.
Omari TI, Rommel N, Staunton E, Lontis R, Goodchild L, Haslam RR, Dent J, Davidson GP. Paradoxical impact of body positioning on gastroesophageal reflux and gastric emptying in the premature neonate. J Pediatr. 2004 Aug;145(2):194-200.
Orenstein SR, Shalaby TM, Putnam PE. Thickened feedings as a cause of increased coughing when used as therapy for gastroesophageal reflux in infants. J Pediatr 1992 Dec;121(6):913-5.
Orenstein SR. Prone positioning in infant gastroesophageal reflux: is elevation of the head worth the trouble? J Pediatr. 1990 Aug;117(2 Pt 1):184-7.
Parrilla Rodriguez AM, Davila Torres RR, Gonzalez Mendez ME, Gorrin Peralta JJ. Knowledge about breastfeeding in mothers of infants with gastroesophageal reflux. P R Health Sci J. 2002 Mar;21(1):25-9.
Ravelli AM, Tobanelli P, Volpi S, Ugazio AG. Vomiting and gastric motility in infants with cow’s milk allergy. J Pediatr Gastroenterol Nutr. 2001 Jan;32(1):59-64.
Salvatore S, Vandenplas Y. Pediatrics. 2002 Nov;110(5):972-84.
Sicherer SH. Clinical aspects of gastrointestinal food allergy in childhood. Pediatrics. 2003 Jun;111(6 Pt 3):1609-16.
Tobin JM, McCloud P, Cameron DJS. Posture and gastro-oesophageal reflux: a case for left lateral positioning. Arch Dis Child 1997;76:254-258.
A Diet for Breastfeeding Moms of Babies with Acid Reflux
Acid reflux can be a temporary or long-term condition in breastfeeding infants. According to the La Leche League International, breastfeeding is often a method of treating gastroesophageal reflux, or GER, which is a more significant form of acid reflux that is characterized by profuse spit-up, breathing difficulties, pain, and even projectile vomiting. Although there are many reasons acid reflux may occur in your breastfeeding infant, they are commonly attributed to your diet.
Significance of Your Diet
It’s important for you to eat a well-balanced diet that isn’t too restricted when you begins breastfeeding. In order for your body to produce nutritious milk and support itself, you must consume 500 extra calories per day, according to KidsHealth.com. MedlinePlus recommends a varied diet with minimal items excluded, unless your baby has given you reason to restrict your diet further, such as developing acid reflux after you consume certain foods. Alcohol, caffeine and any other stimulants should be limited or avoided when nursing. Because water is a key ingredient in breast milk, you need to drink at least 64 ounces of water or caffeine-free fluids per day.
Making small changes to your diet may eliminate or reduce acid reflux in your breastfed baby but not always. Some foods can change the taste of your breast milk, making it more or less appealing to your baby. You don’t need to be overly concerned about omitting spices, dairy or other strong flavors from your diet, unless your baby shows signs of acid reflux or other digestive discomfort, says MedlinePlus. When your breastfed baby develops acid reflux, you’ll want to identify any potential food sources in your diet that are causing your baby’s tummy to get upset. If your baby seems to have reflux after every feeding—regardless of what you have eaten—then your diet may not be to blame. When a known allergy runs in your family, you should discuss it with a health care professional, such as a nutritionist or lactation consultant. It’s possible for your baby to develop an allergy to the food because of exposure in the breast milk. Symptoms of a food allergy, including lactose intolerance, can present themselves in the form of refluxing or projectile vomiting.
Effects of Acid Relux
Babies with acid reflux can exhibit a variety of symptoms during and after nursing. Spitting up is common in any infant, but a baby with acid reflux will produce a greater quantity. The National Digestive Diseases Information Clearinghouse suggests that an infant with reflux will vomit, cough, become irritable, have poor eating habits and may have blood in his stools. As time passes, the baby may not grow at a normal rate from ejecting so much food; however, this is more commonly associated with GER. Wheezing, persistent pneumonia and other respiratory or breathing problems are sometimes the result of untreated GER as well.
Identifying the cause of acid reflux requires some trial and error on the part of you, the parent. Feeding your baby in a more upright position, keeping her upright for 20 to 30 minutes after a meal, and avoiding over-feeding can lead to a reduction in acid reflux. When these steps fail to reduce reflux, you should consider your diet. Keep a journal of everything you eat and drink, including medications, and document how your baby responds after nursing, to help identify potential dietary culprits. Every baby is different when it comes to acid reflux caused by a mother’s diet.
If keeping a food diary isn’t effective in identifying the food source, you may need to carry out an elimination diet. This consists of avoiding all dairy sources for a period of no less than seven days. If, over time, your baby’s reflux improves, then it is likely that he has trouble digesting breastmilk, which contains dairy proteins or lactose, states the La Leche League International. This is not always an indication of lactose intolerance or dairy sensitivity. Further medical testing is needed to confirm an allergy or intolerance as your baby matures. More extreme forms of the elimination diet, such as one discussed by AskDrSears.com, suggest eating lamb, free-range turkey, boiled white or sweet potatoes with salt, rice, green and yellow squash and pears for two weeks. Following the two weeks, one food can be reintroduced to your diet every four days while monitoring your baby for signs of tummy problems or reflux.