Formula Feeding and Reflux: Regurgitating the basics, FFF-style

Let me tell you a little something about infant reflux: it blows chunks.

My second child, Fearlette, had severe GERD and delayed gastric emptying. It was so awful that my husband used to go around singing “Buh-lemic baby/she’s a buh-lemic baby/startin’ em young, here in sunny C.A....yeah, he’s inappropriate, but I love him).

For awhile, we thought it was “normal”. Most babies have some form of mild reflux, and spit up quite a bit. This is because the lower esophageal sphincter, or LES (a little ring of muscles which opens and closes, allowing food in – and in the case of reflux, back out – of the stomach) is immature, and weak, like most of my ex-boyfriends. In some babies, the LES is really underdeveloped, or doesn’t mature fast enough. That’s still within the realm of normal (i.e., just a laundry problem). What isn’t normal is if your baby is visibly uncomfortable – gulping or choking during or after feedings, crying before/after burps, refusing to eat – or is not gaining adequate weight. Also, amounts matter: take a tablespoon of formula and spill it on your counter. Does this look like what is spewing out of your kid’s mouth every hour? That’s considered “normal” (seriously…whoever decided this was “normal” needs to come shampoo my carpets…). If your baby is throwing up a lot more than that per feeding, or if the spit-up is “projectile” (i.e., shooting across the room), then this also may suggest a problem which requires treatment.

If you have a “happy spitter”, and that happy spitter is gaining weight sufficiently, you kind of just have to wait it out. Usually, things get better for kids like that once they start eating solids. (I’d suggest signing up for as many formula coupon resources as possible, because otherwise every time your kid spits up you’re going to see dollar signs. I think watching my daughter vomit entire bottles worth of 30 bucks a can hypoallergenic formula caused me more pain than her reflux ever did to her.) You’ll probably drive yourself nuts switching formulas, when chances are that nothing will help. However, I also am a strong believer in mommy-gut, and if you feel in your heart that your baby’s propensity for geyser-like streams of warm formula could be better handled, then seek help. There are a lot of myths surrounding infant reflux (and infant feeding in general), and if your baby doesn’t seem well, it’s important not to fall victim to those myths.

Onward.

Pretty much every internet resource for reflux will start off by saying you should be breastfeeding. Breastfed kids apparently get less reflux, which is weird, considering how many posts about reflux I see on Kellymom and Mothering.com  from breastfeeding moms… but whatever. Anecdotal evidence aside, it’s the accepted first line of defense against reflux. So who cares about formula? No matter which kind you use, it’s a lost cause. You already screwed it all up, lady.

In all seriousness…true reflux is a physiological issue, and while breastfeeding may prevent the harmless spit up caused by improper bottle technique (things like overfeeding, nipples with too fast a flow, etc.), the fact is that liquid is liquid. If the LES is underdeveloped, it will allow food to come back up – and it won’t really matter if that food is breastmilk or formula. Now, some studies have shown that the severity of the reflux episodes are lessened in breastfed babies – this one even posits a pretty plausible theory that this is due to breastmilk digesting more quickly than formula (as a side note, though, another study states that extensively hydrolyzed whey protein formulas provide similar benefits in that they lead to quicker gastric emptying, which is related to reflux). Regardless, though, the fact remains that breastfed babies get reflux too – and your formula feeding did not “cause” your child to have an under-developed sphincter.

Now that we’ve gotten you over that little guilt roadblock, let’s talk about which formula and bottle to use.

That was a joke.

There is no one-size-fits-all magic bottle and type of formula for reflux. Sure, there are formulas marketed for reflux – these are just normal, milk-based formulas with rice starch added as a thickener. You can also just add your own thickener (on your pediatrician’s recommendation, of course); this allows you to adjust the thickness of the formula and also use a thickener which works for you. You don’t have to use white rice, necessarily – some people use oatmeal, whole grain cereal, Simply Thick, etc. But again, PLEASE ask your doctor first. Adding cereal to a bottle is not a good idea unless it’s done in a controlled way (and if you have a premature infant, it can be incredibly dangerous if not done under the auspices of a physician). Why? Because while  thickened feeds have been proven helpful, they can actually make reflux worse. As this article courtesy of Gaining & Growing states,

…(R)espiratory symptoms associated with GER may be worsened by the addition of cereal to infant bottles. Orenstein et al. (1992) found increased cough in infants with respiratory disease who were given thickened feedings. The addition of cereal to formula feedings may decrease gastric emptying time and actually increase episodes of reflux and aspiration.

And, according to this report from Pediatric Nursing:


Rice cereal used as a thickener increases the caloric density of formula and may cause constipation. Thickened formulas also require enlarged nipple holes to feed, potentially resulting in greater ingestion of air or formula, which can favor regurgitation. Because rice cereal- thickened feedings have 150% of the caloric density of un-thickened feedings, only 65% of the volume needs to be fed per meal; thereby decreasing gastric volume (Orenstein, 2001).

Adding thickener to formula also necessitates finding a nipple which  allows the thickened feed to come through without your poor kid having to suck with all his might, or choke because it’s coming through too quickly. This is much harder than it seems, because while most bottle companies offer a cross-cut or y-cut nipple for thickened feeds, some work better than others. The bottles we’d invested in for Fearlette didn’t make a nipple for thicker liquids, and after mutilating- erm, I mean modifying – a slew of normal nipples after reading online that you can “just widen the hole yourself, we broke down and bought a whole new system. For what it’s worth, we found that the Avent variable-flow nipples worked perfectly – these are actually “slit-cut” (sounds creepy, but whatever), and even the thickest feeds seem to come through just fine. There is a good discussions of this topic here.

Another thing to consider is that reflux might be related to a food intolerance or allergy. Nearly half of all infants with GERD detailed in a 2002 review article had a milk protein intolerance – and in fact, the milk intolerance was provoking the reflux in some of those cases. This was true in both breastfed and formula fed babies. This is where it gets complicated, because if reflux is being exacerbated by other GI issues, it may help to move to a specialty formula. I always recommend a 24-48 hour hypoallergenic “challenge” rather than engaging in invasive testing right off the bat for any suspicion of formula-related GI issues. The way you do this is to buy one or two bottles of a quart-sized ready-to-feed hypoallergenic at the drugstore or grocery store (there are only two on the market in the US – Similac Alimentum and Enfamil Nutramigen), and try them for 1-2 days. Do not give your baby anything but this special formula, otherwise it complicates the “test”. If you see a marked improvement, you have your answer. At this point, if you want to engage in further medical testing to get a definitive diagnosis, you can go ahead and do so…. just be warned that it’s REALLY hard to get a definitive diagnosis of a milk allergy in an infant, unless your kid is one of the rare ones who will test positive on a skin-prick test. Milk allergies are weird, and some experts aren’t even sure if they involve the same reactions as other allergies or are their own separate animal. Not to mention that a severe milk intolerance will often exhibit the same types of symptoms, even though it isn’t a true allergy. See? Told you it was confusing.

As for bottles… during my time perusing the internet, I discovered that Dr. Brown’s and Born Free are the winners in reflux circles. They certainly are great bottles (albeit horrible to clean) and are designed to keep your baby from swallowing too much air, gulping too fast, and so forth. I really do feel that bottles are like relationships – what works for you may not work for me. I go for funny, sarcastic and artistic men, you might like confident, athletic, professional men/women. We all have our preferences. Same with bottles.  I have yet to find a study that looks at the relationship between brand or type of bottle and reflux, so I can’t really give much advice on this. I’m honestly not sure it matters – again, if we’re talking true reflux here, as long as that liquid is going in, it’s gonna come out.

However, there are some mechanical things that make a difference. Feeding your baby at a slight angle – NOT sitting up at a 90 degree angle, as that can make things worse; keeping her upright after a feeding so that the gravity will help keep the liquid down (slings and infant carriers come in handy for this); burping at regular intervals (we would do it after every ounce or two in the beginning, when things were really bad… it never did seem to help, but every medical resource says to do this, so I felt I should mention it). Basically, all just basic good bottle feeding techniques, except for having to keep your baby upright and immobile after feedings. That part sucks. Young babies often fall asleep during feedings, and older babies want to play. Both scenarios pose challenges. That’s why the sling works so well – for younger babies, they can sleep while held at least kind of upright; for older babies, you can keep them upright and somewhat immobile yet still engaged.

I know it all sounds confusing, and it is. As I said before, infant reflux really blows. But the good news is, almost all babies grow out of infant GERD before their first birthday. Although it will probably take a bit of trial and error, I promise you – with the help of a good pediatric GI and some experimentation, you will be able to make your own Bulemic Baby much more comfortable.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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17 thoughts on “Formula Feeding and Reflux: Regurgitating the basics, FFF-style

  1. Great article! I've had 3 ,yup 100% of all my kids as severe refluxers and you are dead right it really does blow!
    All the meds in the world didn't stop my kids from becoming failure to thrive, food aversive and in one kid's case the reflux caused apnea episodes as well.
    I remember almost nothing of all of their first 6 months because it was such a sleepless, screaming filled nightmare (not all their's!).
    A couple of things I've found though – even identifying food allergies may not cure the reflux – sons #1 and #2 didn't have allergies, #3 did but his reflux roared on completely untamed even after going onto hypo-allergenic formula.
    Another thing is, here in New Zealand anyway, they don't recommend thickened feeds until the pain is sorted out because they can have even more damage done by thick, acidic feeds washing up and down as it 'sloshes' more than thinner feeds.
    And it seems that more and more kids aren't out-growing reflux at 1 anymore and that bench-mark has largely been moved to 18 months – again, here in New Zealand at least. I know the docs pushed for my boys to be med-free by 2 yrs old. #1 was by 2 1/2 but back on at 4 1/2 and was clearly refluxing in that med free time, back off around 8 years old but back on around 10 and finally it was surgically fixed aged 10 1/2.
    #2 was off meds around the same time, back on around 4ish and finally had surgery aged 6 3/4.
    #3 never got off meds until surgery aged nearly 4 years and by then the reflux had done such a number on him he was barely eating anything and wound up needing a feeding tube surgically implanted. According to the surgeon #3's oesophagus was so bad it was ulcerated and bleeding – explaining his chronic anaemia too.
    So yup paediatric reflux sucks the life out of you – and the kids!

  2. Wowsers. You have been through the ringer!

    I think you are quite right- one year is probably an optimistic end-point. It's what I was always told, and actually I'd heard that by 6 months they were supposed to start getting better. I was totally shocked when Fearlette started getting worse when we started solids, not better.
    I should have elaborated more on the hypos- my alimentum/nutramigen test is meant as an indicator that an allergy or intolerance is present. Many kids can't tolerate the commercial hypos and need amino acide based formulas, which are only available by prescription here. I probably should've made that clearer! Thanks for all your insight- and I'm so sorry for all that you and your kiddos have been through!

  3. So funny story. My oldest, we'll call him C-bear, had reflux LIKE EVERY OTHER BABY IN THE WORLD. He was breastfed, but vomited about 1/4 cup each time he ate (I gave up everything… dairy, chocolate, green vegetables, spices, CHOCOLATE). So at about two months, he was placed on reflux meds. Around 9 months or so, C-bear stops throwing up every four seconds, so we (as all good parents do) played doctor and dc'd the meds.

    Fast forward two years. Our daughter, we'll call her CA, was born 4 months prematurely, and has vicious reflux. To the point that she will not eat anything by mouth. (She's completely tube fed– peptamin Jr). She sees a slew of specialists each month. At her ENT appointment I had to drag along C-bear. He starts talking to the ENT, and the doctor looks at me and asks, “Did he have reflux? “Sure,” I snorted, “like every.single.other.baby.on.the.planet.” “When did he stop meds?” he asked. “Umm, I stopped them around 9 months.”

    “He has severe scarring on his vocal cords. Can't you tell from his voice?” (C-bear's voice is unusually raspy for a 3 year old, but I kinda like it).

    They scoped him and sure enough, severe scarring from continued reflux.

    Who knew? That stuff is for real, yo.

    And yes, we're parents of the year, in case you were wondering.

  4. Ah the rollercoaster of reflux. Yep it blows big time. My first born was a happy spitter, well more like a happy projectile vomiter. Amazingly she gained weight well, STTN from 8 weeks old and was a dream child. We used reflux meds for several months which helped greatly and by the time she was 10 months old the reflux was pretty much gone. Not sure if it has anything to do with the reflux, but when the terrible twos hit her tantrum was her coughing just enough to make herself vomit… oh that was fun! She's 7 now and thankfully still my dream child 🙂 My 2nd, had severe silent reflux, he would burp up acid then swallow it and scream, we had feeding issues from the get go, he had a milk and soy protein intolerance and just to add some extra fun to the mix, Colic till he was 4 months old. He was on the highest dose of reflux meds the pedi's would allow by 12 weeks old and we didn't wean off meds until he was 13 months. He was on elecare formula from 12 weeks old as well and I sometimes wonder how I didn't go insane in those first 6 months, the kid barely ate and I battled to keep him eating and gaining weight. Thankfully he is now an active, happy 18 month old, still on the small side but he's come a long long way from those early days. Oh he still test my patience every day (the complete opposite of his sister) but he's cute so all is forgiven.

  5. Thank you for posting. My son was just discharged a few days ago after 10 days in the hospital for constant vomiting and failure to thrive. We'd been on Neocate for months but it wasn't making any difference. The hospital did test after test and FINALLY did a gastric emptying test which revealed he has severe gastric emptying delay. Unfortunately, he has lost all interest in eating by mouth and is on an NG feeding tube getting Pediasure around the clock. It looks like we are moving towards a G-tube 🙁 The good news is within 24 hours of getting on medication for the emptying delay, he was a different child, and has not vomited once since we've been home!

    I know my story is extreme (as was my FFF Friday post- my kid doesn't like to play by the rules- I told him he better be a REALLY good teenager) but I encourage anyone dealing with any of this to keep pushing your doctor for answers. When we got to the ER we had to flat out refuse to leave because we were told it was a stomach bug and we needed to go home. We are still searching for a GI doctor we are happy with. It's tough.

  6. Two things really helped our refluxy baby – Neocate (which anyone can order online these days btw, it is not prescription only) and most importantly, the Rock n Play bassinet which is angled and helps baby sleep comfortably.

    Adding anecdotal evidence here in the forlorn hope that while the plural of anecdote is not data, it might help others feel they are not nuts: our baby was wayyyy better after weaning from the breast despite all the elimination diets in the world. Alimentum helped some but Neocate helped much much more.

  7. We're in the middle of the acid reflux battle, but complicated with other issues. My daughter was born with a congenital heart defect and it's super important that she gain an adequate amount of weight so she can have open heart surgery next month to repair the defect. She had trouble with eating from the get go. She spent the first few days of life in the NICU and was fed by IV. She got her first feeding by mouth the day before she came home. We formula fed because she was in the NICU and I have a 3 year old at home. Plus I had postpartum hypertension that put me in bad shape initially. She had trouble latching and would eat a limited amount. When she was about 5 weeks old she had an episode that looked like a seizure and we rushed her to the hospital by ambulance. Turns out it was acid reflux complicated by fluid around her lungs. She's now on lasix (to remove the excess fluid) and pepcid for reflux. She's doing ok and needs periodic increases of her pepcid to keep her from vomiting up most of her bottles. We just hope that she continues to gain an adequate amount of weight so she can have her surgery.

  8. Just to prove FFF's point – my first son was formula fed from the start, never even had colostrom, and could wear the same outfit for 48 hours as a baby without getting it dirty. My second son was exclusively bf and my husband used the measure the distance his vomit travelled across the room. It took cutting out all dairy from my diet and putting him on Zantac to get his vomitting and discomfort under control. He fortunately was one of the the lucky ones who grew out of his reflux fairly quickly but it he definitely shows that something like reflux either will or won't be an issue for your little one regardless of how he or she is fed.

  9. In case anyone is interested, we found that Tommee Tippee also makes a good X-cut “variable flow” nipple for their bottles, which is really great if you are transitioning away from breastfeeding because the shape of the bottles and nipples mimic the roundness of a breast. It was the only bottle my DD would accept for us to give her the thickened formula our doctor had instructed us to start for her reflux and 5 months old. So thankful for that brand even though I loved Born Free for my son.

  10. My eldest son who has a heart defect also had reflux as an infant. Like you I had to battle to get him to gain weight with all his spitting up. Hang in there, it does get better! Those first few years were tough.

  11. Only just popped back here but to cross cut nipples I found you can get a standard one, squash it flat and then cut a tiny cross in the top with a clean pair of nail scissors. That way you can get it as big as you need depending on the thickness of the feed going through!

  12. Okay i’m very curious about something,
    My son was on similac sensitive but he was switched to similac alimentum because of a milk protein allergy and now he’s spitting up all the time! I was told he had reflux (which really blows he’s only 3 weeks old) but on top of spitting up he starts coughing and he gets congested & i was told that it’s normal!? how is that normal!? My poor lil guy. Anywho, I was wondering could the formula be the reason he’s like this?

  13. I am having a similar problem and do not know where to turn. My 9 month old son has had issues with reflux (according to my 3rd pediatrician) since birth. He gains weight and is actually on the healthier side as far as weight is concerned (21 lbs and 31 in). We tried a couple weeks worth of reflux medication and he got no relief; we have been through every formula that you can buy in a store and now within the last 24 hours we have put him on hypoallergenic ready-made formula and he made it 5 bottles into this experiment when he projectile vomited what looked like all 5 bottles at once (8 oz bottles each). We just had a Upper GI done this morning (per 3rd pediatrician) and the Radiologist found nothing abnormal not even anything that would reflect that he even suffers from reflux. I am at a complete loss and don’t know what else to do; after receiving the results from the Upper GI we figured it was food allergy related, but he’s only had the hypo formula and he’s not keeping that down either. My worst fear is any long term damage to this constant vomiting; I’m worried sick about making my son better while the doctors treat me like I’m crazy. any advice?

  14. I have been treating pediatric feeding disorders for many years and have seen patient’s and their families struggle with reflux and feeding frustrations across the spectrum. One ‘treatment’ in particuliar which has made the greatest difference across the caseload without exception has been the addition of a prebiotic paired with a probiotic. Lactobacillis is the one enzyme most depleated in humans and which causes digestion to halt and food to return to the mouth where saliva is in order to breakdown food which is unable to be properly burned for adequate nutrician. Adding a formula with this (Gerber and several other major brands have jumped on the probiotic bandwagon due to the emergence of C-diff and allergic issues we are seeing increase at alarming rates) as well as a form of prebiotic like, inullin, can make all the difference. You will know its working when their bowels begin to stink like something never before and food will progress through to GI track without reversing parastalsis and causing reflux. Give it a try and stick with it for a while, some differences will be obvious immediately but the real benefit will be seen over time. Culturelle is also an excellent product for both infants /peds as well as adults but as with any supplement check with your pediatrician but adding this has made all my patients improve and recover without extensive feeding aversions later. I hope it helps!

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