All you need to know about regurgitation and reflux

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Regurgitation reflux, and your baby - BabyYumYumAre you concerned that you baby may not be keeping enough milk down after feeds? So many babies have feeding issues of some sort, simply because their digestive systems haven’t fully matured yet, which could affect the feeding process.

We all know that breast is best, however, often these digestive problems sneak in during the transition phase from breastfeeding to bottle feeding.

Why does my baby have regurgitation?

Regurgitation usually happens following a feed. The reason for this is, because babies have an immature or weak valve between their stomach and oesophagus (food pipe), allowing the stomach contents to leak back up into your baby’s mouth, making this a common condition which many babies suffer from.

How do I know if my baby has regurgitation?

Your health professional will be able to correctly diagnose regurgitation and symptoms usually include at least four episodes of regurgitation a day for at least 2 weeks in an otherwise healthy baby between the ages of 3 weeks and 12 months.

You can be reassured that enough milk is usually kept down so that your baby is not hungry and grows normally, however, with severe (more than four episodes a day) regurgitation, it is advised that a complete medical history and physical examination be done to rule out conditions such as GORD. Gastro-oesophageal reflux disease (GORD) is a condition in which the reflux of gastric contents in severe enough to require medication and dietary changes.

Is my baby in pain?

Some babies with regurgitation do not seem upset by it. Most of the time, it’s simply a messy business where you feel there is no end to washing clothes! Still, the stomach contents is acidic and can cause the well-known burning sensation and irritation, which could explain the frequent cries often accompanied by reflux in many babies.

What can I do to manage regurgitation?

As always there are many ways how reflux could be managed such as postural therapy, pharmacological and surgical treatments as well as the dietary management of reflux. The management of GORD, which is seldom used in infants between 3 weeks and 12 months of age, includes lifestyle changes as well as pharmacological therapy – mainly acid reducing medication – and, in few cases, surgery. Many studies have failed to show any benefits of medication in the case of severe reflux and often these products can only be recommended for short term use and not as a long term solution. Since BabyYumYum is an online community and resource for parents and caregivers who need information and advice about feeding and nutrition, the focus of this post would be on the dietary options that could possibly help manage reflux.

The nutritional management of regurgitation consists of correcting the frequency and volume of feeds if necessary. If you are bottle feeding and your baby has a simple case of regurgitation (less than 4 episodes a day), adjusting your baby’s feed may be sufficient and should be a first line dietary change recommended in formula-fed infants. There are thickening agents that you can add to your regular formula and also specifically formulated formulas that are already thickened. Both tend to stay in the stomach and not escape so easily back up into the oesophagus. These agents are only to be added on recommendation by your health care professional.

There are many anti-regurgitation/ anti-reflux formulas (AR) on the market, using different starches as the thickening agents, for example: S26 AR, Novalac AR, NAN AR etc. Why is starch added, you may ask? Well, by adding starch, it causes the feed to thicken (increases the formula’s viscosity) once it reaches the stomach, therefore reducing the possibility of regurgitation by reducing both the volume and frequency of regurgitation and crying, improving sleep and supporting weight gain.

Formula feedingHowever, some AR formulas tend to thicken more in the bottle, resulting in air being ingested while feeding and may not be suitable for your baby. Luckily, there are AR formulas on the market which is formulated for babies with regurgitation that remains liquid in the bottle, but only thickens in the stomach, which may be preferred. My best friend’s baby was probably on all of the AR formulas listed in the table below, including Infacare AR( which was discontinued), but the only one that seemed to have this effect of being liquid in the bottle, but still keeps the formula in the stomach due to its thickening properties was Novalac AR.

The everlasting questions remains: how do I know which formula is best and what to do if baby is breastfed? There are 3 main differences between formulas (see table below, which we came across comparing AR formulas available on the SA market), this is where the “boring” detail  comes in for all those mom’s who have an interest in Science:

  1. Some formulas’ protein profile are casein dominant, whereas others are whey dominant. The reason why most AR formulas would be casein dominant is because this type of protein is heavier and in combination with the thickener added to the formula, helps to form a “casein curd” which helps to keep the formula down in the stomach, reducing reflux.
  2. Different thickening agents, such as processed rice, corn or potato starch, guar gum or locust bean gum are used. The key word to focus on in this case is “pre-cooked”, since this allows the thickening agent to only thicken in the stomach and not in the bottle. It also allows for the starch to be easier to be digested and absorbed.
  3. Some formulas have “additives” such as long chain polyunsaturated fatty acids added, which is an advantage since these elements have been reported to play a role in brain and visual development.

There is also data that suggests that a thickened whey partially hydrolysed formula (pHF) may have an effect on symptoms of regurgitation. A thickened partial hydrolysate formula may be slightly more effective than a thickened standard infant formula, possibly because it is easier to digest proteins that are already broken down (referred to as partial hydrolysates). Partial hydrolysates empty the stomach faster than standard protein, which may contribute to a decrease in regurgitation.  An example that we found on the market is Novalac AR Digest, which also has two thickeners added: locust bean gum for an immediate thickening action as well as the pre-cooked starch for a delayed thickening action. We phoned the helpline to find out why there are two types of thickening formulas in the Novalac range and was told that Novalac AR Digest should be recommended for severe reflux, when additional symptoms such as fussiness, arching back, failure to thrive etc. is present. Whereas the Novalac AR1 and AR2 is for babies with mild reflux.

Breastfed vs. formula-fed infants have a similar frequency in physiological GOR, although breastfeed infants have shorter episodes of reflux. As always, mothers of breastfed infants who present with mild symptoms of reflux should be encouraged to continue breastfeeding. In such cases, another product one can consider is Nestargel, which is a special thickener that may be added to feeds. However, it should not be used as a source of nutrition and from experience it is quite a messy and tricky business in itself.

Will my baby grow out of regurgitation?

As the valve linking the stomach and the oesophagus matures, the signs of regurgitation lessen. By the time your baby is 12-15 months of age, symptoms have usually resolved completely. Only a small percentage of children have symptoms after two years of age.

Is there anything else I can do?

  • Avoid clothing or nappies that are too tight.
  • Don’t put your baby to bed immediately after feeding time.
  • Try giving smaller feeds at more frequent intervals.
  • Feed your baby in a calm and relaxed environment.
  • Don’t smoke around your baby.
  • After feeding, place your baby in an upright position and “burp” your baby if possible.

Remember, if you are worried about your baby, always talk to your doctor, clinic sister or pharmacist for more advice.

Table 1: Available anti-regurgitation or reflux formulas in South Africa (taken from Owens et al., 2012)

Class Thickening agent

Used

Brand name Thickening agent used kcal/

100 ml

 

Protein source and

g/100 ml

Carbohydrates

and g/100 ml

 

Additives
  Nan AR® Precooked corn starch 67.0 Demineralised whey

30:70 whey dominant,

1.24

Lactose, potato and

corn starch, 7.7

Novalac AR 1®

Novalac AR2®

Precooked corn starch (thickens

at gastric pH)

1: 66.0

2: 64.3

Skim milk,

80:20 casein dominant,

1:1.6,

2:1.7

Lactose and corn

starch, 7.4

Long-chain

polyunsaturated fatty

acids

Novalac AR

Digest®

Locust-bean gum and

Precooked corn starch

62.8 100% partially

hydrolysed whey,

1.5

Maltodextrin and

lactose, 6.8

Long-chain

polyunsaturated fatty

acids

Thickening

Agent

Nestargel® Carob-bean gum Carob-bean gum

(carob seed flour)

38.0 kcal/

100 g powder

6 g/100 g powder Cellulose

1 g/100 g

hemicellulose

76.2 g/100 g

* = docosahexanoic acid, ** = arachidonic acid

 

Disclaimer: This post is based on personal experience and personal brand preference of the content author and has in no way been paid for or sponsored. BabyYumYum reserves the right to its opinions and fully supports the notion of promotion that breast is best in line with the World Health Organisation (WHO) infant feeding guidelines http://www.who.int/topics/infant_nutrition/en/ Breast milk is the best food for infants. Good maternal nutrition is essential to prepare and maintain breastfeeding. If breastfeeding is not applied, an infant formula may be used according to health professionals’ advice. Preparation and storage of any infant formula should be performed as directed on the tin in order not to pose any health hazards.

47 COMMENTS

    • Hi Andrea
      Thank you for engaging with us.
      What formula is your baby currently on and what is the age of your baby ? please can you supply a bit more detail and we will attempt to assist you .

  1. […] Remember that it is always important to establish which “problem” is the biggest concern at a particular point in time. Sometimes this very same baby who is constantly hungry, but also presenting with reflux might actually need to be on an Anti-Reflux formula instead! At least with these formulas you will definitely address the reflux problem if that is your biggest concern, but would also have a satiety effect (feeling of fuller for longer) too! If you want to know a little bit more on reflux, go read our other blog post here. […]

  2. My 5 weeks old son has been struggling with reflux as well. His pediatrician recommend Novalac AR and it’s working great ?

    • Hi We are so glad to hear that you found a solution for your little one. Its such a relief as a mommy to know that your baby is happy and comfortable , which in turn makes you a very happy mommy !!!

  3. Hi. My 8 weeks old twins are struggling with constipation and smelly gas. They are on s26 gold. Could it be the formula? If so what could be a good substitute?

    • Hi Daphne. Sorry for the delay.
      Are they exclusively on Formula?
      Is there a particular reason why you chose S26 Gold? I’ll be able to give you more information when I have these answers from you.

      • They are on both breast and formula. I have removed some of the food that cause gas especially cabbage, broccoli, cauliflower and beans in my diet. It was a random decision when I chose s26. But if it is the problem I’m willing to change.

  4. My baby is a week old and is suffering from reflux. I have him on Novalac AR1 and I breastfeed as well. He seems to not bring up when I breastfeed at all it’s just when I bottle feed him. It isn’t bad it’s only a little at a time and not more than 4 times a day and sometimes not at all.

    My concern is that he brings up when he is sleeping and I don’t hear it and he ends up choking. I have him sleeping in a positioning pillow and turned on his side. Is this correct? Will my baby still be able to choke in this position??

    • Hi Lurichia, thanks for the interesting question. Just a few questions for you. Why or who suggested that you put your baby onto Novalac AR1? Why was the baby diagnosed with reflux at a week old? Is there any particular reason why you are breastfeeding and formula feeding. By giving us these answers, we will be able to point you in the right direction.

      • I initially only wanted to breastfeed my baby but it turned out I don’t produce enough to satisfy him so I decided to do both breastfeed and formula. When I was in the hospital they gave him Nan Sensitive and I thought it was fine. When I got home I gave him the Nan Sensitive and he brought it up. So we assumed it doesn’t agree with him. It happened a couple of times.

        So my sister in law suggested that we put him on Novalac AR1 which she used for her baby that had severe reflux and it was the only she found that worked. She tried many different formulas.

        The Novalac AR1 seems to work for my baby but he still brings up sometimes. Not with every feed and also not every day. I feed him while he is sitting up right against my chest when bottle feeding and burb him for 30 minutes after each feed. It seems to work.

        I’m just worried about when he is sleeping that he’ll choke if I ended up not getting all the winds out before putting him to bed.

        A doctor friend suggested Nexium but I know that is for severe reflux and as it said my baby doesn’t bring up a lot when he does. My mother in law said it’s normal for babies to bring up a little milk in general, is this true?

        Also my one friend used the Nexium on her baby and she said after 2 weeks she didn’t have reflux anymore. Can this happen? How long does babies usually have reflux and do they grow out of it?

        I apologize I know this is a super long reply. I’m just concerned.

        • Nexium is a schedule 4 drug and is available by prescription only. It is a miracle drug in very severe cases, however, many other options need to be explored before this decision is made.
          We highly recommend that you discuss this with your paed.

  5. hi there, i have been told that Novalac AR causes constipation , is this true. I am about to change from Similac to Novalac AR 1 (my baby has acid reflux) but he is already quite a constipated child. Im concerned its going to get worse.

    • It depends on what the major issue is . . .if baby has gas, then yes you can try Novalac AC, but if the spitting up is possibly reflux, then baby may need to be on a thickened formula like Novalac AR. If you would say it is both then try Novalac HA (it has the thickener of AR, but low lactose like AC. . .) – best of both worlds. . . Might be a good idea to visit a healthcare professional for some advice!

  6. Hi my baby is 6 weeks old.I was advised tho use formula that has AR.I tried NAN AR my challenge is it’s so think if I change from NAN AR to NOVALEC AR won’t it be a problem?

    • There are compositional differences between NAN AR and Novalac AR, however, AR formulas are formulated respectively to assist with reflux by thickening the feed. NAN AR makes use of a lighter protein (whey) and Novalac AR of a heavier protein (casein), however, as mentioned before these differences are based on scientific evidence and have been shown to be effective – it depends on your baby’s need. Novalac AR is known for its thickener to thicken in the stomach to allow for a more variable flow…however, it is important that the correct water temperature and mixing instructions is used to ensure that the thickener dissolves etc. With thickened feeds you can always try a variable flow teat which could assist with the flow as well. Might be a good idea to visit a healthcare professional for some advice.

  7. Hi there, I’ve just started my boy on his first bottle of Novalac AR, how soon is it supposed to work, he is still spitting up after having the bottle.

  8. Hi again, I also should of asked in my previous question, the consistently of the formula is rather watery, its even more so than the similac total comfort that I’ve switched from, is this correct. Im also still expressing and feeding breast milk, will the spitting up/ spewing likely stop once I’ve completely switched over to formula, and lastly how long should I wait before introducing another formula bottle in place of the breast milk? Thanks in advance.

    • Hi Katherine, Novalac AR only thickens in the stomach and not in the bottle. If the spitting does not stop once completely on the formula, baby might need the AR Digest. Should baby be hungry after a feed (breast), mom can top up with her formula.

  9. Hi has anyone herd of Novalc Allenova Smooth? My 13 week has server reflux and not coping on any formula thus far..we have tried nearly 7 diffrent types treating her for a cows milk allergy but unsure if she really has one. She is currently on Neocate but her reflux is terrible on it. We did have her in Novalac AR digest but it gave her server cramps and so much gas. Will Allenova Smooth help her. Does it make them gassy or will it assitance with her reflux and sensitivity?

    • Hi Olivia, Novalac Allernova Smooth will assist with reflux, and the sensitivity, as it is an extensively hydrolysed formula and especially if mom is not sure if baby has allergies. Should they establish that baby has severe allergies, they will then most probably have to move baby onto Novalac Aminova. For now I would suggest she tries the Allernova.

  10. My baby used all the AR products for reflux but due to a lactose allergy we have had to resort to adding thickeners to lactose free formulas. Our current thickener nutilis is very expensive but we cant seem to find a cheaper option

  11. Perhaps someone can help. My Baby girl has reflux. We took her to paed after she started choking on her formula. She would randomly (sometimes an hour after a feed) arch her back stiff, foam at the mouth, battle gargling to catch her breath that her eyes started watering. Paed suggested AR formula and Nexium. She became extremely constipated, would wake during her sleep crying from what I assume is gas and still choked on winds coming up. We tried Similac Total Comfort but the choking got worse and more frequent – we were petrified she would stop breathing or aspirate the fluids into her lungs. We are now using Novalac Allernova but she is vomitting from it. Also pulls away from the bottle…it smells terrible and I’m sure its that she doesnt like the formula? She is extremely fussy since the Allernova and suffering from bad winds and gas. What formula would you recommend? She is 6 weeks and we are not getting any rest.

    • Hi Leanne, it would be beneficial to let her try one type of formula for at least 10 days – 2weeks. Baby needs time to adjust to the new formula each time.
      Have you considered any complimentary treatment like a chiropractor?
      Please let us know once baby has been on Allernova for at least 10 days so we can reassess the situation 🙂

  12. Hi, my baby is weeks old. We put him on Nan AR about 2 or so months ago due to reflux. He is quite gassy and when he burps he takes out quite a bit of milk. He keeps waking up due to the gas. I think he is lactose intolerant like my other child due to the gas and the eczema. Tried putting him on Novalac AR Digest but he is still gassy and has a runny tummy. The gas and poo is stinky which has never been the case before. Please advise what type of formula would be best suited. Thanks.

    • If you suspect your baby is Lactose intolerant I would suggest consulting with your Paediatricians. Should baby be Lactose intolerant, Novalac has a formula called Novalac Allernova Smooth which is lactose free.

  13. Hi my baby girl is 3 months old and after each feed she spitts up some milk several times even after an hour or two after feed. Is it normal pls? I have switched to a lot of formulas to try to find the correct one for her but none of them is good. Now she is on Novalac HA as my doctor told me to try it as it has also some AR in it but still she spits up several times. I was going to try the Novalac AR instead, what do you think? And please can you tell me if the novalac AR makes her constipated or not as other formulas like Novalac AC, stage 1 made her constipated? Thanks a lot

  14. Hi. My baby is on Novalac ar digest and extremely gassy as night time! I breastfeed during the night. Very restless during the night and wakes up constantly. Otherwise happy baby

    • Hi Sumene 🙂 Why is baby on Novalac AR Digest? Are the problems? If baby is happy, continue doing what you are doing 🙂

  15. I am considering moving to Novalac Aminova. Currently on Neocate, but it’s too thin. I know you researched Aminova. Does it really only thicken in the stomach? I ask because I tried the Novalac Allernova recently , which is supposed to only thicken in the tummy. But it was SO thick in the bottle that I struggled even with a variflow teat!

    • If you were on Neocate I would suggest to rather go to Aminova because it is also an amino acid based formula. The Aminova also has a thickener but doesn’t thicken as much as the Allernova Smooth. I would suggest to give Novalac Aminova a go 😊

  16. Good morning my baby girl is 2 months old is breest feeding but reflux and split up all the milk she drink from the first day she was born , i try lot of doctors but they is normal , but to me is not normal when slip up for more that 2 months , 6 try per day, e.g when she drink 200 ml of milk she slip up all of it in less than 2 minutes from the time she drink it.

    • If the doctor didn’t diagnose the baby with allergies, you can try a thickened formula. Novalac has 2 types of thickened formulas that we received good results from. For mild reflux they have the Novalac AR that doesn’t thicken in the bottle, only in the stomach, Nan also has the Nan AR that is a thickened formula. Then Novalac has a formula for babies with severe regurgitation called Novalac AR Digest that have two thickeners in. One that thickens from the start to help with that immediate relief and then one that only thickens in the stomach. The Novalac AR Digest protein is also partially broken down that helps with better digestion of the protein. Maybe you could give a thickened formula a try and see if that will help your baby.

  17. This is one of the most helpful websites I have found. It is so hard to find anything South African based. Please can I ask for your opinion/help. My son was diagnosed with reflux at 4weeks old. Doc put him on 5mg Nexium. At the time he was on NAN. We then tried NAN AR and I found it too thick, kept getting clogged in the bottle so we then moved on to S-26 AR which helped slightly with the pain (he still spits up a lot it is just chunkier now). Fast forward to when he was 12 weeks we saw the doc again, who then increased his nexium to 10mg and suggested we try Novalac AR. Which I did for 3 days and he was so sore so I went back to S-26 AR.
    He is now 4 months old and is back to being in huge amounts of pain, arching, crying etc. Also, as I said before, he still brings up a lot of milk and the spit ups are often painful.
    I have been doing a lot of research and I am now wondering if he has a possible milk protein intolerance and I want to try a partially hydrolised formula that has a higher percentage of whey than casein.
    I saw a homeopath last week and she tested for a lactose intolerance and that came back clear. Also we have been to the chiro a few times.
    I guess I am just asking for some advice on which formula you think I should try next. Similac Total Comfort? Nan Sensitive? A Hypoallergenic one? I am just not sure.
    Any help or advice you could offer would be appreciated.
    Thank you.

    • Hi Wendy, thanks so much for the fabulous feedback!! We love to know that we are able to help 🙂
      We are just going to send this question to an expert and get all the relevant information and get back to you ASAP 🙂

    • Hi Wendy,

      In the first few months of a baby’s life its gut is still immature, sometimes babies will struggle to digest lactose (it’s not to say the baby is lactose intolerant), the lactase enzyme is just not fully developed yet, same with the reflux; the oesophageal sphincter is not fully closing that can be the reason for the reflux. So what you are looking for is something that has low lactose (not no lactose) because you still want to stimulate the lactase enzyme, you want a thickener that will help with the reflux and maybe also a hydrolysed protein due to the fact that the baby may be a bit sensitive to protein. Novalac HA has all 3 of that – hydrolysed protien, low lactose and a thickener. Give it a try and see if that helps. If the problem is more severe reflux – Novalac has one called Novalac AR Digest what is also hydrolysed, reduced lactose but have two thickeners, one that thickens instantly and one later in the stomach.

  18. Hi can you please help. My baby boy is 2 months old and has reflux. Doctor put him on 2.5mg nexium but it made him constipated so I stopped giving him the nexium. Im breastfeeding and giving him Similac total comform however he is still bringing up alot of milk and has alot of gas. Today I brought nan ar but it seems that he doesnt like the milk and it only playing with the bottle. As soon as it put him on my breast he is drinking.. Any advise please?

    • I would suggest to breastfeed as much as possible. Other anti-reflux formulas on the market that perform well are for mild reflux called Novalac AR, that only thickens when in contact with the stomach acids – then the other one is Novalac AR Digest which has a double thickener – one that thickens instantly and the other when in the stomach. It also has reduced lactose and the protein is partially hydrolysed that helps with digestion. Sometimes when the gut is still immature the baby can struggle to digest the lactose and that is when a lower lactose formula works well. So the Novalac AR Digest will solve the cramps and the reflux.

  19. I have been bottle feeding since 2 weeks, my baby is now 4 months old and she’s refusing her bottle. (She’s on NAN1 Optipro) She has been recently screaming her lungs out and arches her back when I try to feed her. She has the signs of reflux, arching back, refusing bottle, coughing, spitting up (very little). I’m just concerned that she is not getting enough nutrition, as she now can go a few more hours without her feed. I have also changed the teat of her bottle to medium flow, it seems to work in feeding time but she’s just not a happy baby while drinking anymore! I read that chiropractors can help, would you advise going that route, visiting a paed, or changing formula?

    • If reflux is an issue, you can try to go on an anti- reflux formula. There are a few on the market Nan AR, Novalac AR. These formulas have a thickener in that can help the baby keep the formula down. The Novalac AR is a good one that only thickens when in contact with the stomach acids where the others I found thickens already in the bottle. 🙂

  20. My baby just got diagnosed with Acid Reflux,she was previously on Nan Optipro and breastfeeding as well.She just turned 6 months a day ago.The Paed prescribed Novalac AR 1 and Nexium 10mg,my worry is if the Dosage of nexium is 10mg at a go doesnt that mean her reflux is severe therefore she needs Novalac Digest instead? and should i wait for the half formula left to finish or i should start with Novalac immediately?

    • If you are going to take the Nexium then the Novalac AR would be fine. I would suggest to go on the AR2 though because it is indicated from 6 months. The Novalac AR by itself will help with the reflux in any way. We always would suggest to go the natural way first, just too see if the formula helps with the problem first before we go to heavy medication for little babies. The Novalac AR Digest has a double thickener, one that thickens instantly and one that thickens in the stomach. I would think that if you use the Nexium with the AR Digest it would be too much.

  21. Hi,

    My 3.5 month old is on Allernova and 10mg Nexium. He is quite constipated so started with a new probiotic with live cultures and/or a little Pegicol to manage that. At a recent pead visit, she recommended moving baby onto Nan Pelargon eventually. She recommended it because apparently it has a thickener, and will help with reflux and constipation. I’ve done some checking, but besides the hygiene factor, I can’t seem to find any evidence that it would help for the reflux? I saw an article that suggested it made the number of reflux episodes worse?
    Do you have any experience with acidified formula?

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