Deborah Howell (Host): About half of all babies spit up several times a day in the first three months of their lives. Reflux in babies is a common, but often challenging issue many parents have to navigate. Today, we're sitting down with Le Bonheur gastroenterologist, Dr. Maggie Vickers, to discuss the different kinds of reflux issues a baby can experience as well as things parents can do to help their child. Welcome to you, Dr. Vickers.

Maggie Vickers, MD: Thank you so much, Deborah. I'm so excited to be here today to be able to talk a little more about infant reflux.

Host: Well then, let's dive right in. What are some common reflux issues that a baby can experience?

Maggie Vickers, MD: So, babies with reflux can experience a wide variety of symptoms, and some of these symptoms may even overlap with other conditions. From a GI standpoint, babies often with reflux will present with recurrent regurgitation, spitting up or vomiting, pain or discomfort, swallowing trouble, or dysphagia. In general, symptoms, some of these may also include discomfort or irritability, failure to thrive or poor growth, or feeding refusal. And then, lastly, sometimes reflux can affect the airway, and so some of those symptoms may include wheezing, stridor, cough, or hoarseness.

Host: Wow, I did not know that last part. Are there different types of reflux?

Maggie Vickers, MD: Yes. So, there are two main types of reflux in infants that are really important to distinguish. So, one is gastroesophageal reflux or GER. And the other is gastroesophageal reflux disease, or GERD, which we will talk more about later in this discussion. In general, gastroesophageal reflux is the involuntary passage of gastric content into the esophagus with or without regurgitation or vomiting. This is a normal physiologic process in healthy infants and even children and adults.

Most episodes are short in duration, meaning they last less than three minutes, occur after a feeding, cause few or no symptoms, and are limited to the very bottom of the esophagus. The majority of babies are what we like to call happy spitters, so meaning they eat well, they're growing well, and they're healthy even though they spit up. Spitting up really doesn't seem to bother them or cause discomfort. In these babies, spitting up is really more of a laundry problem than a health problem. And it's important to remember that babies typically will outgrow this by the time they're 12 to 14 months old.

Host: Good to know. So, what causes reflux in babies?

Maggie Vickers, MD: It's important to remember that 70% of happy, healthy, thriving infants in the first three to seven months of life will spit up. Sometimes this can even be several times a day, and this has to do with the large volume of liquid they are consuming, their horizontal position, meaning they're lying down the majority of the day since they can't sit up on their own, the immaturity of the GI tract, and the limited capacity of the esophagus in newborns. The incidence of reflux typically will peak at four to six months. And then, after age seven to eight months, the frequency and volume of spit up decreases since the infant is now in the upright position the majority of the day. And so, 95% will resolve by 12 to 15 months.

In general, looking a little more as to why reflux occurs, so when we eat, food moves from the mouth through the esophagus, then into the stomach. The esophagus expands and contracts to propel food to the stomach through a series of wave-like movements called peristalsis. At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter. When food enters the top of the esophagus, the lower esophageal sphincter will relax to allow food to enter the stomach, and then it closes to prevent food and acid from flowing backward into the esophagus. Occasionally, the lower esophageal sphincter does not stay closed completely, or it can relax at the wrong time. This then allows the liquids in the stomach to wash back into the esophagus causing an episode of reflux.

So to summarize really, infants consume large amounts of milk and food relative to their small size and the small size of the stomach. The stomachs have poor compliance or stretchiness. So when presented with these large volumes, some of the gastric contents will then reflux back into the esophagus.

Host: Sure. That makes perfect sense. So, at what point does a parent need to loop in a doctor?

Maggie Vickers, MD: So, my main concerns to involve a physician would be feeding refusal or trouble swallowing, vomiting, especially if it's forceful or contains blood or bile, poor weight gain or weight loss, severe irritability or breathing problems. And so, just to mention, vomiting is different than simply spitting up in babies. Vomiting is forceful throwing up of stomach contents through the mouth, whereas spitting up is the easy flow of stomach contents out of the mouth. Frequently, this can occur with burping. And spitting up does not involve forceful muscle contractions, brings up only a small amount of milk, and does not distress your baby or make them uncomfortable.

Host: Good distinctions. Now, this is where we're going to get a little bit more specific. What's the difference between GERD and gastroesophageal reflux?

Maggie Vickers, MD: Yeah. So, gastroesophageal reflux is the passage of gastric contents into the esophagus with or without regurgitation and or vomiting. Gastroesophageal reflux is considered pathologic and referred to as GERD or gastroesophageal reflux disease when the reflux leads to troublesome symptoms that affect daily functioning and/or complications, which in particular in infants, this is when symptoms start to affect growth, cause poor weight gain or weight loss, severe irritability, or it starts to interfere with their feeding.

Host: Now, are there some things, doctor, that you can do at home to help reduce spitting up?

Maggie Vickers, MD: Yeah. So, number one thing would be avoid overfeeding. So if you fill the baby's stomach too full or too fast, it is going to spurt right back out at you. So, try to feed your baby smaller amounts just a little more frequently. Try to burp more often throughout the feeding. Important to keep the infant upright for at least 30 minutes after feeding and limit active play after feeding. For example, it would not be a great idea to do tummy time right after you have fed your baby. Also important to avoid tight diapers or clothing or placing them immediately in the car seat right after feeding. For infants who are on formula, you can try thickening feeds with added rice, cereal, or oatmeal, starting at one teaspoon per ounce of formula, or can try the commercial anti-reflux or added rice formulas, which have the added rice already mixed in.

And then lastly, for formula-fed babies, you can also discuss with your physician about a two to four-week trial of an extensively hydrolyzed formula, which is just a little more broken down than standard formula. And this can sometimes help with reflux due to the effect on the microbiome and stomach emptying, but also some babies with vomiting and poor weight gain may have something completely different, something what we call cow's milk protein allergy rather than simply gastroesophageal reflux. So, this formula is really treatment for that.

Host: Good. And what are some things a breastfeeding mother can do to help with reflux?

Maggie Vickers, MD: Yeah. So likewise, in formula-fed babies, the breastfeeding mother can also try doing smaller, more frequent feeds, burping frequently during the feed or when she switches sides. She can also try thickening feeds in mothers who pump. However, in comparison to the formula-fed baby, this would have to be in discussion with their physician. And they would need to use a commercial thickener. The mom, lastly, can also try a temporary elimination of dairy and soy in her diet. And this would be for treatment for possible cow's milk protein allergy in case there is that overlap.

Host: And they call it that for infants rather than, say, lactose intolerance for adults?

Maggie Vickers, MD: So, this is completely different. In infants, you can get a cow's milk protein allergy, which is more of an intolerance and inability to break down the milk protein. Where in comparison to adults, lactose intolerance is more of a difficulty with the milk carbohydrate or milk sugar. And so in adults, lactose intolerance can cause more symptoms of diarrhea, bloating, gas, and belly pain.

Host: Okay. One's a protein, one's a sugar. Okay. Well, Dr. Vickers, thank you so much for talking to us today about navigating our baby's tummy troubles. I learned a lot, and I'm sure our audience did too.

Maggie Vickers, MD: Great. Thank you all so much for having me today. It was my pleasure.

Host: This is The Peds Pod by Le Bonheur Children's Hospital. Please visit lebonheur.org for all your pediatric needs. I'm Deborah Howell. Thanks for listening and have yourself a great day.