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Managing regurgitation and reflux in your baby

by BabyYumYum
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We all hear that breast is best, but often digestive problems such as reflux or regurgitation sneak in during the transition phase from breastfeeding to bottle feeding. Are you concerned that your baby may not be keeping enough milk down after feeds?

Many babies have feeding issues of some sort simply because their digestive systems haven’t fully matured yet, which could affect the feeding process.

Q. Why does my baby have regurgitation?

Regurgitation is a common problem that usually happens following a feed. 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.

Q: How do I know if my baby has regurgitation?

Symptoms usually include at least four episodes of regurgitation a day for at least two weeks in an otherwise healthy baby between the ages of three weeks and 12 months. With severe regurgitation (more than four episodes a day), it is advised that a complete medical history and physical examination be done to rule out gastro-oesophageal reflux disease (GERD). This is a condition where the reflux of gastric contents is severe enough to require medication and dietary changes.

Q. Is my baby in pain?

Most of the time, it’s simply a messy business where you feel there is no end to washing clothes! Still, the stomach contents are acidic and can cause burning sensation and irritation, which could explain the frequent cries often accompanied by reflux in many babies.

“The nutritional management of regurgitation consists of correcting the frequency and volume of feeds if necessary.”

Q. What can I do to manage regurgitation?

There are many ways to manage reflux such as postural therapy, medication and surgical treatments, as well as the dietary management of reflux. The management of GORD, which is seldom used in infants between three weeks and 12 months of age, includes lifestyle changes as well as acid reducing medication and, in a 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. In this post, we focus 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’re bottle feeding and your baby has a simple case of regurgitation (less than four 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, as well as 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 and NAN AR. Adding starch thickens the feed thereby reducing both the volume and frequency of regurgitation and crying, which supports weight gain and improves quality of sleep. However, some AR formulas may not be suitable you’re your baby as they tend to thicken too much in the bottle, resulting in air being ingested while feeding. Luckily, there are AR formulas on the market that are formulated for babies with regurgitation that remains liquid in the bottle but only thickens in the stomach.

The question remains: how to know which formula is best and what to do if your baby is breastfed. There are three main differences between formulas (see Table 1 below, which we came across when comparing the AR formulas available on the SA market).

1. Some formulas’ protein profile are casein dominant, whereas others are whey dominant. Most AR formulas would be casein dominant because this type of protein is heavier. In combination with the thickener added to the formula, this helps to form a “casein curd” which helps to keep the formula down in the stomach and reduce 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 were told that Novalac AR1 and AR2 are for babies with mild reflux, while Novalac AR Digest should be recommended for severe reflux, when additional symptoms such as fussiness, arching back, failure to thrive, etc. are present.

Breastfed vs. formula-fed infants have a similar frequency in physiological GOR, although breastfed infants have shorter episodes of reflux. Mothers of breastfed infants that present with mild symptoms of reflux should be encouraged to continue breastfeeding and speak to their paediatrician.

Q. 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 should have resolved completely. Only a small percentage of children have symptoms after two years of age.

Q. 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”, if possible.

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

Brand nameThickening agent usedKcal/100mlProtein source and g/100mlCarbohydrates and g/100mlAdditives
Nan AR®Pre-cooked corn starch67.0Demineralised whey
30:70 whey dominant,
Lactose, potato and corn starch, 7.7 
Novalac AR 1®Pre-cooked corn starch (thickens at gastric pH)66.0Skim milk,
80:20 casein dominant,
Novalac AR 2®Pre-cooked corn starch (thickens at gastric pH)64.3Skim milk,
80:20 casein dominant,
Lactose and corn starch, 7.4Long-chain polyun-saturated fatty acids

Novalac AR


Locust-bean gum and pre-cooked corn starch62.8100% partially hydrolysed whey, 1.5Maltodextrin and lactose, 6.8Long-chain polyun-saturated fatty acids

Table 1: Available anti-regurgitation or reflux formulas in South Africa (taken from Owens et al., 2012)
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 the advice of healthcare professionals. Preparation and storage of any infant formula should be performed as directed on the tin in order not to pose any health hazards.

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