All you need to know about regurgitation and reflux

Regurgitation reflux, and your baby - BabyYumYumAre you concerned that your 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 a recommendation by your healthcare 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.