Silent reflux in babies

Reflux is often talked about in mothers' groups and parent circles. It usually comes up when a baby seems uncomfortable or is spitting up a lot of milk. But, sometimes, reflux can go completely undetected.

Here’s what to look out for if you suspect your baby is suffering from silent reflux, and the steps you can take to manage it.

What is reflux versus silent reflux?

In basic terms, reflux is when acid comes up from your little one's stomach and burns their throat. You may know that feeling yourself after you’ve eaten too fast or had a lot of fatty, fried foods or spicy foods. Ouch!

As adults, this is often called 'heartburn.' The causes of heartburn in adults can differ from infant reflux. The feeling is the same. It is that terrible burning sensation. Acid rises up your esophagus and even into your mouth.

And this pain is why a baby with reflux cries. A lot.

Check out our article that talks about what reflux is, and the various degrees and different types of reflux. This will help you understand what may be happening to your wee one’s digestive system to cause such discomfort.

Right now, we want to focus on silent reflux. This is also called laryngopharyngeal reflux or LPR, which is different to gastroesophageal reflux/GERD. Silent reflux can be harder to notice than regular reflux. It may be affecting your baby’s sleep and other things.

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What’s so silent about silent reflux?

In the case of silent reflux, babies swallow the milk that comes up their oesophagus (food pipe) instead of spilling or spitting up.

Since you don’t see your little one throwing up, the symptoms aren’t always clear. That’s why it’s called ‘silent’.

Not knowing what’s causing your little one pain can be extremely heart wrenching. You might question every choice you make as a parent or caregiver. You may wonder when you will have a “normal” baby. You want a baby who is more settled and not feel so stressed.

Symptoms of LPR/silent reflux

Crying (and crying and crying and crying…)

Tears, or maybe screams, are how your baby shows they are uncomfortable. However, many babies with reflux do not cry. Instead, they may be hard to settle or get to sleep.

But first thing’s first. Just because your baby is crying a lot doesn’t mean they have silent reflux.

There may be a number of underlying issues causing them tears. Make sure to rule out everything on our list that may cause your baby to cry, before suspecting silent reflux.

Problems feeding

Whether your baby is on the breast or bottle, there will likely be some feeding issues for an infant with silent reflux.

While sucking, they may gag (dry retch) and cough. They may seem “fussy” and pull off the breast or bottle, and in extreme cases refuse to feed much at all.

Some reflux babies will "snack" often. This can happen because feeding hurts, so they keep stopping. It can also be soothing when more milk goes down and pushes acid back down. They may also have difficulty swallowing or burping.

Often babies with severe silent reflux will be seen to arch their back while feeding or just afterward.

So, will taking a bottle help?

There seems to be a misconception that reflux occurs more in breastfed babies, but changing from breast to formula feeding will usually not solve the problem. It’s the act of having liquid in their tummies that matters.

Sleeping issues

Babies suffering from silent reflux will probably not be great sleepers. They often take a long time to fall asleep. Once they are asleep, they may wake up after just a few minutes, often screaming suddenly.

You may find that your baby only settles when lying upright, either on you or in a baby carrier. This is because being upright offers the advantage of gravity, so acid and milk can’t go upwards.

If your baby is not settling, the sleep deprivation kicks in - for both your baby and you. This, and seeing your baby in discomfort can leave you at your wits end!

That said, there are some babies with reflux who will sleep well during the day and night. It’s possible they’re simply exhausted or they may not ‘reflux’ too much overnight.

Other reflux signs

As well as the above, a baby with silent reflux may also suffer from one or more of the following:

• Coughing, but without other sickness symptoms (this is their natural reaction to acid hitting the back of their throat)

• Being really noisy and making strange sounds like gagging, grunting and having a hoarse voice

• It may seem they are more “mucusy” than other babies

• They may drool a lot more (some parents will confuse this with teething)

• They may pick up frequent colds and ear infections

• Have bad breath.

• Bubbles around their mouth

• Hiccuping frequently

For babies with severe silent reflux (very rare), things can get really bad. Look out for:

• Constipation and /or diarrhoea

• Discolouration of poop

• Not thriving (very little weight gain or even weight loss)

• Terrible congestion, and in extreme cases, difficulties breathing and even apnea (stopping breathing).

Remember the issues we’ve listed here are not always going to show up on a child suffering from silent reflux. Every child presents differently and will react differently to their levels of discomfort.

If you are suspicious silent reflux is playing havoc, follow your gut (excuse the pun) and see your GP or health professional right away.

Most doctors agree that a mother’s intuition should always be listened to!

Diagnosis of reflux

Diagnosis is often done by a GP or specialist based on symptoms explained by the parents. If you think your baby has silent reflux, write down the signs your baby may show.

Babies with reflux can be very happy when they are distracted. People, including doctors, may not think they are in much pain.

It's a great idea to take a video of when they are having an episode to take along for your appointment.

There are a few diagnostic tests that can be done: Barium swallow series, PH probe and Upper GI Endoscopy.

Is it possible my baby is just tired?

Absolutely. In fact, it’s more likely that this is the problem, statistically speaking.

If a baby cries a lot and is often irritable, it’s important to think about other reasons. Your baby might be over-tired, under-tired, or overstimulated.

Too often babies end up being put on reflux medication unnecessarily, when all they really needed was for their napping and feeding to be more structured according to their age.

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The best way to rule out tiredness or overstimulation is to ensure your baby sleeps well for their age. Our age-specific Sleep Solutions can give you a helping hand here.

Then, if your baby is still not sleeping after trying our Sleep Solutions, you may consider silent reflux and perhaps try some of the tips in this post.

If things still don’t improve, chat to your GP or specialist as soon as possible.

Day to day management of silent reflux

If you suspect silent reflux and have ruled out under / overtiredness, give some of these ideas a try

Keep baby upright during the day

Hold your baby upright when they are awake. This helps prevent liquid from coming up easily.

Be sensitive to their tummies

By this, we mean keeping as little pressure on their little stomachs as possible as this will bring up more acid.

If tummy time is uncomfortable, don’t push it. Although this position is key for their early development, it’s not going to be effective if it really hurts them.

Keep this time short if they start crying, then sit them upright, or put a cushion (a feeding cushion is good) under their torso.

Using tight baby carriers can also cause discomfort to your little one if they have silent reflux. Be gentle when winding too.

Feeding tips

• Breastfeed / bottle feed in a more upright position, i.e. baby’s legs down as opposed to across your body

• If you produce a lot of milk and it seems to be gushing out, so your baby is guzzling, sit back so the flow is slower. If you’re bottle feeding, try a slow-flow bottle/teat.

• After feeding keep your baby upright for 30 minutes – usually over your shoulder. Avoid putting your baby in a car seat right after feeding. The bumping in a laid-back position can be uncomfortable.

• Try giving your baby smaller feeds more often (unless the feeds are already small and frequent, which may be the case)

• Burp/wind during each feeding, ideally when they pause, rather than pulling them off. Babies with reflux will often have trouble burping and may need a lot more time to get there.

Breastfeeding or donor breast milk & your diet

As breastfeeding mummas know, what you eat is passed through your milk. Altering a mother's food intake can sometimes help with reflux.

This isn't easy, though, because it's hard to know exactly what foods are triggering the reflux. There are so many factors at play.

You might notice that some foods upset your baby. Foods like coffee, chocolate, and citrus fruits can make reflux worse.

If your baby has reflux due to an intolerance, it is less common. The usual cause of reflux is an immature valve. The main foods that can cause this intolerance are dairy, soy, and wheat.

Be careful. As a breastfeeding mother, you need many nutrients. We suggest talking to your doctor before changing your diet.

Pacifiers

Pacifiers (or ‘dummies’) can help soothe the baby by encouraging them to swallow saliva which may be enough to wash the acid down and help with the pain.

Settling a baby to sleep with silent reflux

So, you and your doctor have determined that silent reflux is a problem for your baby. But how do you get them settling to sleep better?

Firstly, make sure you hold your baby upright at least 30 minutes before you attempt to lie them down.

Sleep coaching a baby with reflux can definitely be a challenge. It’s important to help your baby feel comfortable and reduce his pain. You also want to avoid any bad sleep habits that could affect their sleep later.

We strongly recommend that you avoid using a "cry it out" method for sleep training. This is especially important if your baby or child has silent reflux.

We believe that a more gentle approach is required. Babies do well with routines. For babies with silent reflux or other health issues, a good sleep schedule is important. It helps you see if the reflux comes back or gets worse.

Our Sleep Solutions consider babies with reflux. We can provide tips to help your little one settle down faster and more easily.

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Note: Do not incline the crib/cot

Many health care professionals still recommend elevating a crib ever so slightly - for example, by putting a small book under the front wheels, or a small towel under the hard mattress.

But the American Academy of Pediatrics published a report in 2016, concluding that elevating the head of the crib is not effective in reducing reflux and instead increases the chance of SIDs. (Report states, “It may result in the infant sliding to the foot of the crib into a position that may compromise respiration and therefore is not recommended”).

Medical treatment of silent reflux

Medications

Infant Gaviscon works as an antacid to neutralise stomach acids and a thickener. It’s often recommended to breast-fed infants in place of thickened formula (see your doctor first).

Medication such as omeprazole (often packaged under the brand name ‘Losec’) or Ranitidine may be considered by your doctor, for the small number of babies that have silent reflux.

These meds work to neutralise the acid in the tummy, so when liquid comes up the oesophagus it doesn’t burn. They generally provide instant relief for mild reflux. For severe reflux your doctor may try other medications.

Note the dosage depends on weight, the baby’s age, and severity of symptoms, so don’t go giving your baby these drugs if you happen to have these common drugs in the cupboard. In general, they’re only recommended for babies with poor weight gain or significant distress from reflux.

If the medications you take do not work, your doctor might test you for allergies. They may also refer you to a gastro specialist. This specialist can look into your issues more closely with tests that are more invasive.

Definitely contact your GP if your baby is not feeding, is losing weight, is more unsettled than normal or you suspect they have reflux.

Milk thickeners

Your doctor may also recommend thickening agents to mix with formula, which can often really help reflux.

Breathing issues

If reflux is affecting your baby’s respiration, your doctor may give you a sleep apnea monitor. If you see any breathing issues you must see your doctor urgently.

Natural remedies for silent reflux

Some mothers find the following more alternative approaches can help relieve silent reflux symptoms:

• Baby massage therapy (you can learn to do this yourself)

• Osteopath cranial sacral treatments

• Probiotics (make sure you have the correct strains of bacteria)

• Gripe Water, Colic Calm, or other homeopathic remedies.

Introducing solids to a baby with silent reflux

It would be great to provide a clear list of foods that reflux babies can eat. However, every baby is different when it comes to reflux.

Some health professionals recommend using baby rice cereal to thicken formula or expressed breastmilk of a baby with reflux before six months, to help keep the milk down. We would recommend only doing this under the advice of your doctor.

Although fruits are part of a normal “starting-solids” regime, you may like to tread lightly and only attempt very small amounts of new foods.

Acidic fruit like green apples or tomato (yes, this is a fruit!) and bananas may cause a flare up as well.

When will my baby grow out of silent reflux?

There’s no specific rule for when silent reflux will disappear, but specialists agree that it’s generally an issue for the first few months only, as a baby’s sphincter muscle is able to start blocking liquid coming up the oesophagus.

Most parents see that signs of reflux disappear when their babies can sit up, or eat solid food.

What if my child is not growing out of silent reflux?

If your older baby or toddler still shows symptoms of silent reflux, despite eating solids and their digestive system maturing, they may have ongoing silent reflux issues that should be addressed medically.

This is very rare, but shouldn’t be ruled out. Here are some common signs that toddlers or older kids may still be suffering:

• Speech development: They stop babbling or talking, perhaps in response to pain, or have a hoarse voice

• They have teeth that show signs of erosion

• Eating issues: be fussy over certain foods and textures

• Endless ear infections

• They may remain clingy and cranky (behavioural result from being in constant discomfort).

Life after silent reflux

Unfortunately, some babies who have suffered from silent reflux and recovered (either through treatment or age), could still continue to wake frequently, catnap, and need to be fully assisted to sleep.

This is often the result of never having had a chance to learn to sleep that well.

If you need extra help teaching healthy sleep patterns, have a look around our website and check out our comprehensive Sleep Solutions.

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References:

Pavlov, I. P. (1928). Lectures on conditioned reflexes. (Translated by W.H. Gantt) London: Allen and Unwin.