Reflux is a condition where babies spit up milk from their stomach. This happens when digestive juices flow back up into the food pipe (esophagus) from the stomach. This flow of food and digestive juices may cause a burning sensation and pain. When the baby spits up, it usually contains undigested milk.

Posseting is when infants bring up a small amount (usually a teaspoonful or less) of milk, either breast or formula, without seeming to mind. Posseting is common among babies under six months old, and it isn't caused by a medical condition and doesn't require medication.

Reflux symptoms include spitting up after eating, crying if fed, having a red face, thrashing, flailing their arms and legs, pulling their legs up, and generally seeming uncomfortable. Babies who have reflux may also vomit after feeding. It is worth noting that the symptoms of reflux are similar to cow's milk allergy and colic, so it is important to get a proper diagnosis to ensure your baby gets properly treated and prevent over diagnosis.

There are two main types of reflux - acid reflux and nonacid reflux. Acid reflux occurs when the baby has too much acid from the stomach, which refluxes back up to the oesophagus, causing pain and discomfort. Nonacid reflux usually occurs due to too much food in the stomach or overfeeding. The food contents (which contains acid) then move back up into the oesophagus, causing discomfort and pain.

What causes reflux? (Gastro-oesophageal reflux)

Most cases of reflux occur before the age of three months. Reflux is symptoms of an underlying cause which can be a combination of factors, including:

• Too much fluid in the stomach
• A weak sucking reflex
• An immature swallowing reflex
• A low birth weight
• An immature sphincter
• A traumatic birthing experience
• A tongue tie
• Fast flow of breast milk and over supply
• Allergies

An immature sphincter is essentially a doorway between the stomach and the oesophagus. This sphincter opens to let food into the stomach and closes again after entering the stomach. Its job essentially is to stop stomach contents from coming back up into the stomach. However, in babies, this sphincter is not quite mature enough. This sphincter is a muscle and, like all muscles, has to 'learn' to work in a certain way.

The medical term for this is gastro-oesophageal reflux (GER). If you think your baby has this, you are not alone. Up to 80% of babies suffer from it in the first few months of life. Reflux symptoms are usually not severe and subside by 12 to 18 months. But severe GER can cause your baby to spit up and cry a lot, even when they are hungry for food this is then termed Gastroesophageal Reflux Disease (GORD)

Symptoms include:

• Frequent spitting up after eating, often with large amounts of milk coming out;
• Refusal of food, bending away from the bottle or breast and hungry behaviour when food is refused;
• Extreme fussiness and crying - especially after eating;
• Crying that sounds painful or is more than normal crying;
• Gagging or retching when eating or spitting out;
• Difficulty sleeping due to discomfort;
• Damp belching or hiccups;
• Respiratory complications such as wheezing or frequent coughing.
• Wanting to feed constantly and wanting to feed large volumes.

Reflux is common and not necessarily bad.

Reflux is common and not necessarily bad, and it occurs in almost every baby. Some doctors even think that a little spitting up (or reflux) is normal in babies and does not need to be treated at all.

But in other babies, reflux is something more serious. Either way, a baby with frequent reflux may need medication or support. Knowing the signs will help you decide if you should talk to your paediatrician about treatment options for your baby.

In the case of more severe spitting up or other GOR symptoms, there is usually a cause of this. Severe GOR - is known as Gastroesophageal Reflux Disease GORD  and is usually the the symptom of something else, possibly an allergy, most likely Cow's Milk Allergy. Find out more about how Cow's Milk Allergy is diagnosed here.

Medication can help, but it is not the only option.

Reflux medications are usually unnecessary and only help in approximately 20% off cases.

The main reasons for taking reflux medication are:

• To help your baby sleep better at night
• To help your baby gain more weight
• To relieve pain in the baby
• To help you as parents get some sleep

In most cases, reflux disease is overcome in babies by 12-18 months, so medication is not usually needed. Medication should only be used if your baby is stressed, in pain or not gaining enough weight.

Medication for reflux can have some unpleasant side effects, such as gastrointestinal bleeding, uncomfortable wind, constipation or diarrhoea. The anti-reflux medication increases the pH of the stomach juices, making them less acidic. The acidic environment of our stomach is essential to kill bacteria and viruses, so raising the pH could increase the chance of your baby being exposed to bacteria and viruses. For a baby with an immature immune system and microbiome, this could cause them to get sick. Therefore it is essential to talk to your doctor first before treating your baby with reflux medication!

Sometimes, changing your baby's milk formula can help.

Babies spit up, and this is a fact of life. So if your baby spits up all the time, do not worry. It most likely has an immature digestive system and will get rid of it quickly.

However, sometimes vomiting can be a sign of reflux disease (Gastroesophageal Reflux Disease) in babies, where the stomach contents flow back through the oesophagus into the mouth. Frequent vomiting can cause your baby to vomit violently, which is particularly worrying in newborns who cannot yet lift their heads. It can also cause your baby to be restless and unhappy (especially after feeding) and spit up or choke on milk during feedings.

These tips can make a big different.

• Smaller, more frequent feedings.
• Keep your baby upright for 30 minutes after eating.
• Keep your baby's head elevated while holding them by placing a pillow under the
• Upper back to raise the shoulders slightly above the head.
• Elevate their cot, so their head is higher than their feet.
• Let your baby burp several times during meals and hold him upright for at least 10 minutes afterwards.
• Avoid overfeeding
• Trying to avoid them from swallowing air from crying by feeding them when they show cues of hunger and before they become distressed and ensuring that your baby has a really good latch during breast feeding. If latch is poor consider getting them checked for a tongue tie.
• Make sure when bottle feeding that the teat is filled with milk at all times during feeding.

Feeding Position

The baby's position can affect how much milk flows back after breastfeeding. I make sure the babies head is higher than their feet, and gravity can help keep the milk in the tummy. After a feed, burping is also important and often helps get rid of swallowed air.

Bottle-fed babies.

• Babies should be placed upright when bottle-feeding and burped every two to three ounces until they have finished the bottle.
• Babies who have frequent problems with reflux will benefit from taking smaller amounts during one feeding session and more servings during the day.
• Babies can be supported with a bottle-feeding pillow or infant-sized pillow, which is a small pillow that you place under the baby's head to prop them up while they feed.
• If your baby is unsettled or irritable during feeding, try a different position, such as 'sitting up with the bottle-feeding pillow under the baby's back.
• Be careful not to overfeed your baby as too much milk will force the oesophageal; sphincter to open and move stomach contents back up into the oesophagus and cause pain. It may seem that your baby wants to feed a lot and often. This is a symptom. Your baby feels relief when feeding! Feeding little and often is better.

Breastfed Babies

When feeding a breastfed baby, burping is generally easier as milk flow is slower. You can gently roll your baby's shoulders from side to side and pat your baby's back to help them burp up their extra air.

Feeding should usually only take 20-45 minutes. It may be helpful to try different breastfeeding positions if you find the classic cradle hold painful for you or uncomfortable for your baby. You could try the football or clutch to allow a better latch and improve milk flow. Breastfed babies are often able to continue feeding when they feel satisfied. If your baby is still hungry, he will let you know by rooting around and sucking harder. This is good practice, as it helps teach your baby to eat when they are truly hungry.

Thickener

Thickening agents such as carob or rice cereal or ground porridge oats can help thicken food (by adding them to expressed breast milk or formula) so that it is less likely to reflux once it reaches the stomach. Adding thickeners to expressed breast milk or formula does not affect the nutritional content but may reduce the palatability of the milk by making it thicker and stickier. Adding thickeners or using pre thickened milk or gaviscon may help in some babies but is not always the best solution because they can cause wind, gas, constipation or diarrhoea. It is best to consult a dietitian or other health care professional who can advise appropriately. Have a look at by 'Settle Your Baby' Masterclass for some guidance on pre-thickened milks and thickeners.

Other Options:

Changing the feeding pattern

Milk feeds must be given in a particular way to avoid reflux problems.
You will need to make sure your baby is upright for at least 15 minutes after each feed and that you take smaller amounts of milk. If your baby still has reflux, talk to a doctor or specialist.

Changing the feeding method

Correct teat size - Some babies do not tolerate certain types of teats or bottles. Try different types until you find one that works for your baby.

Give your baby's stomach time to empty after drinking from a bottle.

Make sure to feed small amounts but give some space between feeds, trying to keep your baby elevated to allow the milk to empty into the small intestine and be removed from the stomach,

"Feeding on-demand"

A baby knows their own body best so feeding on demand is generally a good process to follow, especially for breastfed babies. Babies with reflux often instinctively drink smaller quantities at a time, so following their lead rather than what a textbook says or another baby of the same age is doing is better. Please remember every single child is different, so the way we feed and parent them should be different. What works for one does not always work for another. So if it is expected that your child should be drinking so much milk at so much age and time and your child is not following this pattern, then please do not worry. As long as your baby is growing well and meeting its milestones, these symptoms can be managed.

Paying special attention to sleep

If your baby is fussy or unhappy, it takes a long time for them to settle after a feed. Burping them gently and keeping them upright until they are ready to sleep will help the milk pass through their system more easily.

Silent reflux in babies

Some babies don't spit out what they eat but swallow it instead. Even if there aren't any spitting up, they might show other symptoms similar to regurgitation, such as crying or feeling unsettled after feedings or having a cough or hoarse voice. In severe cases, babies may have symptoms similar to GORD. This is called silent reflux, and treatment is similar to the treatment given for GORD.

Let your baby burp frequently during feedings to reduce discomfort from trapped air bubbles.

Babies are born with a strong tendency to suck on anything they touch or feel near their mouths, and this reflex is essential for breastfeeding and contributes to babies being less likely to spit milk out through their noses.

By the time a baby is about five months old, this reflex is usually gone. If it continues to occur, it may mean that your baby is swallowing too much air while breastfeeding. If you let your baby burp every few minutes during meals, you can relieve this discomfort and prevent him from spitting out a lot of milk at the end of a meal.

Babies have an immature digestive system that makes them spit up easily, especially after large amounts. Babies can spit up anywhere from once a day to several times an hour, and no one knows why some babies are more prone to reflux than others.

Reflux in babies is not fun for them, but it can be manageable and, in some cases, even go away on its own.

It is frustrating when you know that everything you are doing is right, but your baby's reflux still will not go away. It is hard to see your baby in pain, and there is not much information about reflux. Many parents are confused because they do not know how to help their baby, how long it will take or if you are even doing the right thing. I hope this information will reassure you and give. Please reach out to me if you have any questions or concerns.

If you are unsure your baby has reflux and find you are confused by information on the internet or possibly you feel unsupported from your GP, then have a look at my 'Settling Your Baby Masterclass'. This masterclass helps you to identify your baby's symptoms so that you are clearer about what is possibly going on, with practical easy to implement solutions that really do help.