Does your baby have acid reflux, or are they just barfy?

Morgan Nish really wanted to breastfeed her first baby, Isaac, but supply issues meant she had to switch to formula when her son was two weeks old. That’s when the projectile puke problems started—and the amount of spit-up dribbling down Nish’s shoulder after a feed was much more than what she thought was normal. “He was happier, because he was full,” she recalls. “But if I was holding him in a cradle position and he’d puke, it would go all the way up into my hair. I’d have to go shower at two o’clock in the morning. We had receiving blankets all over the house to clean up the mess.”

Over the next few weeks, the vomiting didn’t improve. Isaac was also colicky, with prolonged bouts of unexplained crying. Because Nish’s apartment didn’t have a washing machine, she scrubbed barfy blankets in the bathtub to save money, all the while becoming physically and emotionally exhausted. “I remember feeling so inadequate as a mother,” Nish says.“I thought, ‘Why should I have kids if I can’t even feed them?’” She had worked as a registered nurse before taking her mat leave and knew from her medical training that she was technically doing everything right, but it sure didn’t feel like it. “Deep down you know those feelings are irrational, but you still can’t help having them,” she says.

Different studies have found a real range when it comes to total numbers, but somewhere between 40 and 70 percent of infants spit up every day. Even though it’s common, it’s still distressing for new parents—especially if the baby is crying and upset afterwards. Did they barf because they’re overfull? Or because you, the nursing mom, ate something that disagrees with their tummy? Should you try a different formula? Is the baby crying because they’re in pain from heartburn and acid reflux, or are they crying simply because they’re hungry again, after vomiting up the entire feed? It can be pretty overwhelming for a puke-covered new parent to process.

Acid reflux in babies is not the same as plain old reflux

There are a few reasons healthy babies spit up or vomit. The most common cause is that a newborn’s stomach is still developing—including the esophageal sphincter muscles that keep milk from spilling up and out. Infants drink a lot for their body size, and they have a short esophagus.

“Therefore, some of the large volume intake simply overflows upward, or sometimes ‘spills’ out through the mouth,” paediatric gastroenterologist Eric Hassall wrote in The Journal of Pediatrics. He explains that regular reflux is when a baby regurgitates milk or formula but is otherwise content and gaining weight at a healthy rate. With acid reflux, stomach acids move back into the esophagus and cause painful heartburn-like symptoms, feeding difficulties, weight issues, and coughing or choking.

Doctors used to widely prescribed acid-suppressing drugs to treat acid reflux in babies. However, studies now show these medications often do more harm than good. Last fall, Health Canada issued a new warning about ranitidine, one of the drugs sometimes prescribed as a remedy for babies with acid reflux: Ranitidine can contain small amounts of N-nitrosodimethylamine (NDMA), a toxin that may cause cancer. Drug manufacturers then recalled at least 20 products, including the one sold under the brand name Zantac, and started conducting additional testing for NDMA levels.

Hassall has been arguing that doctors over-prescribe medications for gastroesophageal reflux disease (also known as GERD) for years. In a 2012 article titled “Over-Prescription of Acid-Suppressing Medications in Infants: How It Came About, Why It’s Wrong, and What to Do About It,” Hassall says that the acid-suppressing drugs (including H2RA blockers, like ranitidine, and the more potent proton-pump inhibitors, or PPIs) that are highly effective for acid reflux in older kids and adolescents should hardly ever be used for infants, except in very specific circumstances.

“Especially in infants, in the first few months of life, spitting up is a normal phenomenon,” explains Hassall, who is now retired from his paediatric clinical practice. He thinks that GERD (the more severe, chronic version of acid reflux) and acid reflux in babies are over-diagnosed simply because most newborns cry a lot: A baby starts wailing, can’t soothe itself and keeps on crying. “A lot of doctors will say, ‘Because the infant is spitting up and unhappy all the time, driving parents crazy with unexplained crying, it must be because the reflux is hurting the baby.’” Parents and doctors often associate the regurgitation and crying as cause and effect, even when they shouldn’t be linked.

The good news: Between three and five months of age, both the crying and the spitting up usually lessen, and, by the time your baby is 12 to 15 months old, 95 percent of reflux issues go away without any treatment.

“As long as the infant is happy most of the time and thriving and growing, then it’s not GERD,” says Hassall. “In the great majority of cases, it’s not acid reflux, it’s reflux—and it’s a self-resolving condition.” If it’s just reflux, he says, we shouldn’t treat it.

This isn’t to say that crying has no cause or that acid reflux disease doesn’t exist. Some infants do have GERD. It’s much more common if the baby has cerebral palsy; if the baby had surgery for a congenital abnormality of the esophagus or stomach; or if they have cystic fibrosis or another chronic lung disease. A doctor would also want to rule out a bowel obstruction or what’s called pyloric stenosis, which is a blockage in the stomach. (With this condition, the puke is noticeably projectile—like an arc that extends several feet).

The pros and cons of acid reflux drugs

If vomiting or spitting up is a concern, bring it up with your paediatrician or family doctor, but don’t be surprised if they tell you to wait it out.

This is the advice Michael Dickinson, a paediatrician in Miramichi, NB, and past-president of the Canadian Paediatric Society, gives frequently, especially if a baby is peeing, pooping, gaining weight and not overly irritable. “If this was a baby that was doing a lot of spitting up but was otherwise healthy, what we would call ‘a happy spitter,’ typically we would do nothing,” he says. “We would just provide reassurance and ongoing monitoring that the baby was still feeding well and gaining weight.” This treatment plan—one that avoids drugs—is backed by the organization Choosing Wisely Canada, which uses medical research to reduce unnecessary tests and treatments.

However, it’s not always possible to follow best practices in real life. “When the milk is flying everywhere in the house and you’re having to do laundry 10 times a day, I think it can be a very frustrating symptom,” Dickinson says. “It’s very common for parents to be quite concerned.” Some parents push for a drug solution to “fix” the vomiting, and some doctors may give in, he explains.

It’s also important to note that the ranitidine recalls are an ongoing process: the drug companies can fix the manufacturing issues that caused the impurity, and after conducting additional testing for NDMA, they have been reapplying to Health Canada to get the medications back on the market. The more powerful PPI drugs used for acid reflux are also still available.

This type of drug is what Nish’s paediatrician suggested for Isaac—he prescribed Losec, which also goes by the generic name omeprazole. (There are six different types of PPIs available in Canada. You might also recognize brand names such as Prevacid and Prilosec.) But Nish says the Losec didn’t seem to make much of a difference after a couple weeks, so, on the advice of her doctor, she stopped giving it to Isaac.

The problem with acid-suppressing drugs, especially proton-pump inhibitors, is that stomach acid plays a vital role in fending off infection and absorbing essential nutrients, such as calcium, magnesium and iron, says Hassall. These drugs can cause increased rates of pneumonia, diarrhea, and vitamin deficiencies (like iron and B12). If parents do give their child an acid-suppressing drug to treat reflux, Hassall says it should be a short, two-week trial only. If things don’t improve, explore other options.

Non-medical treatment for reflux and acid reflux in babies

Some doctors suggest parents try more frequent feedings while decreasing the amount at each feed (or shorter nursing sessions, if you’re breastfeeding).

Dickinson says parents can also experiment with keeping the baby more upright. “And try not to jiggle the baby after a feed,” he adds. But even these tips don’t always work, he admits. “I’m usually underwhelmed with the response,” he says. “If babies are spitters, they’re going to let loose anyhow.” Plus, many babies need a diaper change after a feed, which inevitably involves laying them down flat on their backs then picking them up again—at which point they will likely spew all over your shoulder or down your back.

On the advice of Isaac’s paediatrician, Nish tried using a small wedge to prop up his crib mattress so his head was slightly elevated, at about five to 10 degrees. “That was the only thing that worked,” she says. But even that option can be dicey: Safe-sleep recommendations outline that a baby should sleep on a firm, flat surface, and never at an incline of more than 10 degrees. (Young babies could slide down the mattress into an unsafe position.)

In April 2019, the Fisher-Price Rock ’n Play, an inclined sleeper that was popular with parents of reflux babies (because it elevates the baby’s head at about a 30-degree angle) was recalled in the US after it was linked to 32 infant deaths. By November 2019, the Consumer Product Safety Commission had issued a warning about all inclined sleepers, not just the Rock ’n Play, estimating the total number of deaths from multiple brands had reached 73. (In Canada, Rock ’n Plays weren’t officially recalled because they weren’t labelled as sleeping devices; they were called “soothing seats.”)

Using a more upright or inclined swing, bouncer or car seat could even increase vomiting, says Teresa Pitman, a La Leche League leader in Guelph, Ont., who has also written several books on babies and breastfeeding. “That can often cause the baby to spit up more because the angle of the seat compresses the stomach,” she says.

Instead, Pitman says using a carrier or wrap, or holding your baby upright, can sometimes help. That’s the strategy she used with her first son, Matthew, to encourage him to burp up any air and keep more milk down. “He used to spit up after every feed,” she says. “Receiving blankets were like a joke. I actually carried a towel around with me.”

Poor latch or a mom with a fast letdown or faster flow of milk might also cause a breastfed baby to swallow more air and spit up, says Pitman. There are other signs of a latch issue. “You might notice some soreness when you’re breasteeding; the baby might seem to be struggling a bit at the breast, and maybe pulling off,” she explains. Connect with a public health nurse, lactation consultant or a La Leche League group.

In breastfed babies, Hassall says regurgitation can sometimes be connected to a food allergy or intolerance, but nursing moms should always talk to a doctor first before changing their own diet. There isn’t a ton of quality scientific evidence proving that what a mom eats causes issues in a breastfed baby. Plus, elimination diets can be unnecessarily gruelling and limiting for a new mom who’s nursing around the clock. But anecdotally, some doctors, including Hassall, still believe it can make a difference. “I’ve seen innumerable cases where eliminating a specific food from the mother’s diet has had a significant effect,” Hassall says. He recommends eliminating some common proteins, starting with cow’s milk products. Soy, seafood and eggs could also be culprits. “Later, after the child is older than six months, you can start reintroducing those foods into your own diet in small amounts,” Hassall says.

Keep in mind, though, that even if you cut out dairy for a month, for example, and the barfing seems to lessen, your baby is also one month older—they may have outgrown the reflux by then anyway.

Parents who formula-feed may want to talk to their doctor about trying different types. Hypoallergenic formulas are more expensive, but the cow’s milk protein in them is easier to digest.

Waiting it out

In most cases, time, patience and a lot of laundry are the best cures for infant reflux. Nish’s son started vomiting less and sleeping better around the four-month mark. Today, he’s a healthy seven-year-old and she has three more kids. (While Scarlett, now three, was a puker, her two other kids, Mia, five, and Brooklyn, 15 months, were not.) Pitman says that Matthew stopped spitting up entirely by the time he was nine months old, and all that early puking had no ill effects. She went on to have three more kids and none of them rivalled their oldest brother when it came to puking. “The others spat up, too, but not as much as he did,” Pitman recalls. “He spat up after every single feed.”

Being told to wait it out certainly isn’t easy to hear when you’re wiping vomit off your couch and clothes all day long. But when Nish thinks back to those early days with Isaac, she hopes that sharing her story will help other parents. The barfing stage might last six months, or even 12 months—which definitely feels like an eternity when you’re stuck in an endless cycle of feeding, spit-up, sleepless nights, laundry and more laundry—but “it does not last forever,” she says. “Sometimes it's literally taking things one minute at a time. Take a break for yourself, and make sure that you’re vocal if you need self-care, like if you need to go take a bath for 10 minutes or you need to listen to music for 15 minutes. Moms are famous for putting themselves last, and putting their kids first. But your mental health is important, too.”

How do I know if my baby has reflux?