Reflux in Infants: Breast Milk Vs. Formula
Reflux occurs when the opening to the stomach relaxes, allowing the contents to escape back toward the throat. This happens commonly in infants and often results in spitting up. Less frequently, reflux may cause vomiting or irritability. Reflux occurs in both breastfed or formula-fed infants. However, a study published in July 2009 in the "Acta Paediatrica" journal demonstrated that reflux episodes occurred less frequently in breastfed infants. In most cases, mild reflux in infants is harmless and resolves on its own as the digestive tract grows. Even so, there are treatment options that may be helpful, especially for infants with frequent symptoms.
Treatment in Breastfed Infants
Breastfed babies gain protection against common infections and have a reduced risk of sudden infant death syndrome, among other health benefits. Given these advantages, breastfeeding is encouraged for all infants -- including those with reflux. According to the October 2009 guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), reflux in some infants occurs due to an allergy to proteins in cow’s milk 1. These proteins may pass to infants via breast milk if the mother is consuming cow's milk. For this reason, NASPGHAN recommends that breastfeeding mothers try avoiding cow’s milk as well as eggs in their diet to see if removing these allergy-provoking foods leads to reduced infant reflux.
Treatment in Formula-Fed Infants
Formula-fed infants may also experience reflux as a result of sensitivity to the proteins in cow’s milk. For this reason, NASPGHAN recommends a trial of amino acid or hydrolyzed formula (Neocate, EleCare), as the proteins in these formulas are broken down and less likely to cause a reaction. Thickening formula is also recommended -- but any form of formula thickening should only be performed after consulting a doctor to ensure the proper amounts of formula and thickener are used. Rice cereal is often used to thicken formula for reflux, and while it may be helpful, it may also increase infant coughing. There are anti-regurgitation formulas (Aptamil, Celia) available that already contain thickening agents.
Lifestyle Modifications and Medications
There are lifestyle modifications that can help infants with reflux, regardless of whether they are breastfed or formula-fed. The American Academy of Pediatrics recommends decreasing the volume of feedings, but increasing their frequency 34. This should be done with the guidance of a doctor to make sure the baby is receiving adequate nutrition. It can also be beneficial to keep an infant in an upright position for at least 1 hour after feeding. Placement in a baby seat that leaves the infant in a partially reclined position is not recommended as this can aggravate reflux. With mild reflux symptoms, medications are not usually needed. However, if the baby is having ongoing discomfort or not gaining weight as expected and other measures fail, acid-reducing medications such as famotidine (Pepcid) or ranitidine (Zantac) may be prescribed.
Warnings and Precautions
While mild reflux symptoms are usually harmless, more severe symptoms may indicate a serious problem. Seek medical advice immediately if any of the following signs or symptoms occur: -- Bloody vomit or stools. -- Fever or persistent irritability. -- Inability to keep feedings down or vomiting in large amounts. -- Wheezing or rashes. -- Failure to gain appropriate weight. -- Frequent refusal of feedings. -- Failure of symptoms to improve with conservative treatment.
Medical advisor: Jonathan E. Aviv, M.D., FACS
- Journal of Pediatric Gastroenterology and Nutrition: Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
- Acta Paediatrica: Natural Evolution of Regurgitation in Healthy Infants
- American Academy of Pediatrics: Gastroesophageal Reflux: Management Guidance for the Pediatrician
- American Academy of Pediatrics: GERD/Reflux
- U.S. Department of Health and Human Services: The Surgeon General’s Call to Action to Support Breastfeeding
- Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci. 2017;18(8). doi:10.3390/ijms18081671
- Galos F, Boboc C, Balgradean M. Gas reflux in children with normal acid exposure of the oesofagus. Maedica (Buchar). 2016;11(4):345-348.
- Behrman: Nelson Textbook of Pediatrics, 17th ed. Saunders.
- Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications? Gold BD - Am J Med - 6-SEP-2004; 117 Suppl 5A: 23S-29S.
- North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Guidelines on Pediatric GERD. J Pediatr Gastroenterol Nur, Vol 32, Suppl. 2, 2001.
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