Is your baby unsettled or having trouble sleeping because of reflux?

Does reflux cause unsettled baby behaviour?

Do you worry that your baby is crying from reflux or wind pain when you put her down? You might have heard that reflux pain will make her dial up or cry when she's flat on her back, and interfere with her sleep. Parents find it reassuring to know this is now proven not to be the case.

All babies reflux. Sometimes the reflux just runs a little way into the oesophagus, then falls back into the stomach. Sometimes it rises up towards the mouth. In this case, you might hear or see your baby swallowing back down some reflux, but you don't need to worry. Often the reflux flows out of your baby's mouth into a puke or vomit, even quite forcefully sometimes. Puking or vomiting tend to occur most frequently around four months of age. But again, you don't need to worry about it. Reflux doesn't cause your baby to wake excessively at night or have sleep problems or cry a lot.

Reflux is close to pH neutral for about two hours after a feed, whether the feed is breast milk or formula. That is, most baby reflux isn't acidic and reflux doesn’t cause our babies pain.

If your baby is fussing and arching his back during breastfeeds, this most likely signals underlying problems with the baby's fit and hold, resulting in an unstable feeding position. I recommend you seek the support of a NDC accredited health professional. If your baby is fussing and arching his back during bottle feeds, please read about paced bottle feeding here. An acute gut infection (or gastroenteritis) may cause vomiting, which resolves. Just occasionally, frequent and projectile vomits are due to an underlying medical condition such as pyloric stenosis or a food protein induced enteropathy syndrome. Please consult with your GP if you have concerns about your baby's health.

What does the research say about baby reflux?

Here are some reassuring things about reflux which are clearly proven now in the research.

• Babies in the first year of life typically don't have oesophageal inflammation, even when very unsettled. Endoscopies have shown oesophageal inflammation occurs only rarely in babies, and many of those rare cases recover without treatment, anyway.

• Reflux doesn't cause disrupted baby sleep.

• Babies don't swallow large amounts of air, even when they have breastfeeding problems.

• Babies puke or vomit more when they

  • Are dialled up (but you still don't need to worry about it), because a dialled up sympathetic nervous causes more reflux, and also because the tummy muscles contract with crying, causing reflux

  • Have a full tummy (but that doesn't mean you can't offer the breast again if you think baby wants this!)

  • Have pressure placed on their tummy (for example, in a supported sitting position - but you still don't need to worry about it).

• There are now many studies proving that antacid medications (such as omeprazole) don’t make babies cry less, or sleep better. Unfortunately, these medications do have possible side-effects.

Why does your baby cry when you put him down if it isn't reflux?

It's biologically normal for babies to dial up when we put them down, because they hunger for sensory nourishment and the comfort of being in someone's arms. They aren't crying because of oesophageal or gut pain.

However, this means it can be hard for you to get a break, especially if you are the primary carer. That's a whole other hugely important topic. Firstly, we need to deal with excessive night waking or daytime sleep concerns. Secondly, we need to make sure your own needs are being met, which I discuss in the section called 'Caring for you'. A third idea if your baby doesn't like to be put down is to experiment with using a baby carrier, so you have free hands.

As you work through the Possums programs, you'll try out different ways of understanding and working with your baby's behavior, including the way she dials up when you put her down. These new ways of making sense of her behaviour actually make the days and nights easier, not harder. But it can all seem very different to start with.

I know you'll just experiment your way through to find what's right for you, since you know your baby best.

Selected research

Cuzzolin L, Locci C, Chicconi E, Antonucci R. Clinical use of gastric antisecretory drugs in pediatric patients with gastroesophageal reflux disease: a narrative review. Translational Pediatrics. 2023;12(2):260-270.

Drall KM, Hein MT, Kozyrskyj AL. Commentary: the influence of proton pump inhibitors on the fecal microbiome of infants with a gastroesophageal reflux - a prospective longitudinal intervention study. Frontiers in Cellular and Infection Microbiology. 2018:doi:10.3389/fcrimb.2018.00430.

Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.

Douglas P. The rise and fall of infant reflux. In: Finkel E, editor. The best Australian science writing 2012. Sydney: New South 2011. p. 62-78.

Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49(4):e252-e256.

Douglas PS, Hill PS, Brodribb W. The unsettled baby: how complexity science helps. Arch Dis Child. 2011;96:793-797.

Fernandez-Gonzalez SM, Moreno-Alvarez A, Solar-Boga A. Proton pump inhibitors in pediatric gastroesophageal reflux disease: a systematic review of randomized controlled trials. Children. 2024;11:296.

Gieruszczak-Bialek D, Konarska Z, Skorka A, Vandenplas Y, Szajewska H. No effect of proton pump inhibitors on crying and irritability in infants: systematic review of randomized controlled trials. Journal of Pediatrics. 2015;166:767-770.

Kolodziej M, Bieruszczak-Biatek D, Piescik-Lech M. Overuse continues despite no new evidence on the efficacy of proton pump inhibitors for crying and irritability in infants. Acta Paediatrica. 2021;111(3):682-683.

Levy EI, Hoang DM, Vandenplas Y. The effects of proton pump inhibitors on the microbiome in young children. Acta Paediatrica. 2019;109:1531-1538.

Malchodi L, Wagner K, Susi A, Gorman GH, Hisle-Gorman E. Early antacid exposure increases fracture risk in young children. Pediatics. 2019;144(1):e20182625.

Mitre E, Susi A, Kropp LE, Schwartz DJ, Gorman GH, Nylund CM. Association between use of acid-suppressive medications and antibiotics during infancy and allergic diseases in early childhood. JAMA Pediatrics. 2018:doi:10.1001/jamapediatrics.2018.0315.

Pappa A, Muschaweck M, Wenzl TG. Change of sleep stage during gastroesophageal reflux in infants. Children. 2023;10(5):836.

Sultana Z, Yildiz V, Jadcherla SR. Characteristics of esophageal refluxate and symptoms in infants compared between pre-treatment and on treatment with proton pump inhibitors. Journal of Perinatology. 2023:https://doi.org/10.1038/s41372-41023-01825-y.

Tan J, Jeffries S, Carr R. A review of histamine-2 receptor antagonist and proton pump inhibitor therapy for Gastroesophageal Reflux Disease in neonates and infants. Pediatric Drugs. 2023;25:557-576.

Tighe MP, Andrews E, Liddicoat I. Pharmacological treatment of gastro-oesophageal reflux in children (Review). Cochrane Database of Systematic Reviews. 2023(8):Art.No:CD008550.

Wang Y-H, Wintzell V, Ludvigsson JF, Svanstrom H, Pasternake B. Association between proton pump inhibitor use and risk of asthma in children. JAMA Pediatrics. 2021;175(4):394-401.

Wolf ER, Sabo RT, Lavallee M. Overuse of reflux medications in infants. Pediatrics. 2023;151(3):doi:10.1542/peds.2022-058330.