DOES MY BABY HAVE REFLUX?

Spitting up is very common in infants, and in most cases, it is completely normal. Studies show that over half of all infants under 3 months spit up daily. This type of spit-up or reflux is called gastroesophageal reflux (GER); it is not associated with discomfort and is completely unproblematic for your baby.

It is primarily because the infant's digestive system is still developing, and conditions in the baby's body make it easier for stomach contents to flow back up into the esophagus. For most, reflux is a physiological condition that peaks around 4 months and subsides again by 12–14 months of age.

However, in some children, symptoms become more pronounced and are accompanied by discomfort, crying, and restlessness. This is referred to as problematic reflux or gastroesophageal reflux disease (GERD).

There is also a more hidden form called silent reflux, where the child does not visibly spit up but still experiences discomfort from the reflux.

Research and clinical guidelines describe a number of typical symptoms of reflux such as:

• Frequent spitting up or vomiting
• Irritability, restlessness and malaise, especially during or after meals
• Baby does not like lying flat on their back
• Tense or stiff body
• Frequent arching of the body like a "bow"
• Pronounced crying or discontent
• Restless sleep and frequent awakenings
• Shorter naps and difficulty settling down

In addition, you may also see:

• “Wet burps” or visible discomfort when burping
• Hiccups and frequent regurgitation sounds
• Redness around the eyes or on the face that occurs along with the discomfort
• Blocked nose without a cold
• Preference for being upright or sleeping on a parent’s chest
• Aversion to car seats or curled-up positions

With silent reflux, many symptoms are the same, but since spitting up or vomiting is not visible here, the symptoms can be more hidden:

• Swallowing sounds or frequent swallowing
• Sound of reflux without the spit-up coming out
• “Wet” breathing, smacking or chewing
• Coughing, hoarseness or wheezing
• Feeding difficulties or rejection of the breast/bottle
• Choking or having “coughing fits”
• Sudden bodily restlessness and discomfort without visible spitting up
• Feeding difficulties

Common to both types is that they affect the child's well-being and the entire family's everyday life.

It is important to emphasize that the type and number of symptoms vary; not all babies show the same signs, and not all crying is due to reflux. These symptoms can also be caused by other reasons and should therefore always be evaluated by a healthcare professional to rule out other explanations.

Reflux in infants is rarely caused by a single factor. Research indicates that the cause may be one or more contributing mechanisms:

Studies suggest that the composition of gut bacteria, also known as the gut microbiome or gut flora, plays an important role in an infant's digestion and well-being.

Among other things, gut bacteria help to:

• Break down nutrients from milk
• Mature the immune system
• Protect against intestinal irritation

Gut flora varies naturally from baby to baby. In some infants, the composition of the flora may be less balanced and varied, which can affect digestion and contribute to symptoms such as restlessness, stomach discomfort, or reflux. 

The autonomic nervous system automatically controls the body's functions, including digestion and muscle tone. Infants have a more immature nervous system, so this system is still under development. This may mean that the regulation of digestion is not yet working optimally. When this interaction is not fully mature, stomach contents can more easily flow back into the esophagus and cause reflux.

Infants also have a limited ability for self-regulation, which can amplify physical discomfort. They are still learning how to regulate calmness and tension, so restlessness in the body and the environment can intensify symptoms. Some babies are more sensitive and react more strongly to internal discomfort, which can make the symptoms more pronounced.

The control of the lower esophageal sphincter (LES), located at the junction of the esophagus and the stomach, is not yet fully developed. In addition, the baby’s diet is liquid and they have a short esophagus, which also increases the risk of reflux. 

The diaphragm, the large breathing muscle between the chest and abdomen, also plays a role. If there is tension here, it can affect the pressure in the abdominal cavity and thus have an impact on reflux.

Increased pressure in the abdomen can make it easier for stomach contents to flow back into the esophagus and cause reflux. In infants, this pressure can be affected by factors such as restlessness, crying, hiccups, physical activity, or gas in the stomach.

At the same time, the child's coordination between breathing and digestion is still developing. This means that the interaction between the stomach, esophagus, and breathing is not always functioning optimally yet, which can also contribute to reflux.

There are several gentle measures you can try to support your baby:

Keep your baby upright for 20–30 minutes after feeding to reduce reflux.

Smaller and more frequent meals; it can be easier for the child to digest smaller amounts at a time. When breastfeeding, an "open milk bar" is often recommended, and for bottle-feeding, smaller amounts more often throughout the day.

Please be aware that a good breastfeeding position and the way the baby suckles can influence whether the baby swallows air, which may lead to air-based reflux in some infants.  

When bottle-feeding, side-lying or upright "paced bottle feeding" and the type of bottle used can reduce air intake.

In some infants, cow's milk protein allergy or sensitivity may play a role and should be evaluated in collaboration with healthcare professionals. This involves investigating whether the child reacts to specific foods, such as milk protein, eggs, and soy, by using an elimination diet for 2-4 weeks. If your baby is on formula, the possibility of using extensively hydrolyzed or amino acid-based formula to completely or partially alleviate the reflux will be tested.

Lactic acid bacteria specifically for infants may have an effect on some infants with reflux.

These tips may help reduce discomfort, but will not remove the cause of the reflux:

• Consider carrying your baby in a sling or other carrier.                                                         
• Turn your baby onto their side when changing diapers instead of lifting their legs up.                               
• Lay your baby down on their side, instead of on their back, especially the left side; this minimizes the risk of milk flowing into the esophagus when you lay your baby down.                                          
• Let your baby lie on their stomach or side while supervised
• Elevate the head of the bed so the baby is lying at a slight incline

Close skin-to-skin contact can help the nervous system find calm and reduce restlessness. It can also be in the form of gentle touch or massage, calm rhythmic movements, or gentle pressure. 

Fewer stimuli can make it easier for the child to self-regulate. Create predictability, structure, and familiarity in everyday life. 

Although more research is still needed, current evidence suggests that gentle manual treatment can be a relevant supplement for some families, as manual therapy can reduce symptoms of reflux without reported side effects.

The treatment works with the body's mobility and balance; it is very gentle and performed using soft techniques, based on the child and their needs. The purpose is, among other things, to:

• Relax the diaphragm and abdomen
• Improve mobility in the chest and back
• Support the autonomic nervous system
• Create better balance in the body

Many parents find that their baby becomes calmer, sleeps better, and thrives more in everyday life after treatment.

Acid-suppressing medication is only recommended when there are clear indications and in selected cases, as the effect is limited and side effects are possible. This is always done in consultation with your GP or pediatrician.

Always contact a doctor or health visitor if your baby:

• Is not gaining weight
• Has persistent feeding problems
• Appears to be in pain, cries a lot, and is difficult to comfort
• Has breathing difficulties

You may also consider an assessment by a practitioner with experience in infants if the symptoms are affecting your daily life and your baby:

• Is very tense and arches their back
• Cries a lot, is difficult to comfort, or often seems fussy
• Shows signs of reflux or silent reflux
• Swallows a lot of air or clicks when feeding
• Sleeps restlessly and often wakes up crying