If your baby has acid reflux, their sleep can suffer. You may find yourself holding your little one in an upright position to minimize the symptoms of reflux.
What is Acid Reflux in Babies?
The American Academy of Pediatrics defines acid reflux as is the movement of the contents of the stomach into the esophagus, and sometimes through the mouth and nose. Your baby's esophagus is also known as your baby's food pipe. It's located in your baby's throat and connects the mouth to the stomach. Acid reflux causes stomach acid to rise up into the esophagus, leading to pain and discomfort. This can be distressing to the baby and the parent. It can sometimes make feeding a challenge, in addition, this understandably makes it difficult for babies to sleep well. As a parent, it's distressing to see your little one in discomfort and losing sleep.
What are the Symptoms of Acid Reflux in Babies
Reflux in babies can present in many different manners. Reflux exists on a continuum. Meaning the symptoms may vary in severity from child to child. Many kids are “happy spitters.” They spit up but it doesn’t seem to bother them. They show no signs of pain or distress. In some babies you might not actually see them spit up at all, this is called Silent Reflux. According to the American Academy of Pediatrics (AAP), the more serious form of reflux is the medical condition, gastro-oesophageal reflux disease GERD.
The AAP describes the symptoms of GERD as the following:
- Refusal to feed
- Crying and/or arching the back during feeds (i.e., seems to be in pain)
- Blood or greenish color in the spit-up
- Increase in frequency or intensity of the spit-up (i.e., forceful)
- Belly is swollen or distended or feels hard
- Respiratory symptoms—including wheezing and coughing
These are the obvious signs of severe reflux which make it easy to get medical advice from your baby's pediatrician and a diagnosis of reflux. Your baby's doctor will likely give you these recommendations.
The people who tend to struggle quiet are parents of babies who don't visibly spit up. This is called Silent Reflux. Often these babies will not let you put them in the supine position, or on their back. I'm well versed in this since my daughter had this and I've worked with hundreds of parents who didn't realize their babies had silent reflux, but did find that their babies would "ONLY SLEEP IN ARMS." Baby's sleep can definitely be affect by infant reflux. You can read more about that in this blog post.
Signs of Silent Reflux
You might not notice your baby has silent reflux because you didn't know what to look for. Obvious signs of reflux such as actually spitting up, poor weight gain, arching away from the breast or bottle weren't necessarily present.
Baby's Symptoms Might Look Like this:
- Fussy baby when put her her back
- Seems to tolerate sleeping on her stomach or in arms better than on her back
- Naps that seem to only last 20 minutes in the crib but hours in arms
- You might notice she seems to "swallow fluid" away from feeding times
- A grimace, possibly accompanied by a red face, and then swallowing
- Sharp cries in the middle of sleep
- Noticeable coughing - as your baby coughs to clear the stomach contents that have regurgitated from the back of her throat
- Congestion in the morning
- Wet spots on the mattress in the morning
- Sleeping better in arms or on someone
Why Your Reflux Baby Struggles With Sleep
- She’s gassy. I’ve found that babies with reflux, they often can be challenging to burp. The feeling of needing to burp can cause them to take short naps or wake more frequently in the night.
- She feels pain. The acid splashes up into her esophagus and she wakes up because of it.
- For babies over 4 months, over time you’ve held her upright to fall asleep, and she’s associated that falling asleep looks like being held upright. So when she wakes in the night, like all humans do, she wants/needs to be held to fall back asleep.
- For older babies, you’ve now got a little PTSD. Those first few months with a baby who has reflux are so stressful. She’s been in pain or uncomfortable and now you’re programmed to jump at the slightest toot. Your worry meter is super sensitive.
- Because of the stress you’ve been through, you have doubt that she’s capable of sleeping long age appropriate stretches.
If you’re struggling with reflux and lack of sleep, the first thing you need to do is get the reflux under control so let's talk more about the root causes of Reflux that people are not talking about!
Your baby's doctor will likely give you these recommendations:
(Keep reading for the things that they won't tell you about that can help!)
- Keep them upright after feeding. Hold your baby upright for 30 minutes after feeding so gravity can help keep acid down. You can also try propping up one end of the crib mattress to keep them inclined.
- Give a warm bath before bed. A warm (not hot) bath can help relax muscles and make acid reflux symptoms feel better before laying down to sleep.
- Use a wedge pillow. Placing your baby at an incline on a wedge pillow can allow gravity to keep acid from rising up. Look for an adjustable wedge to find the ideal angle.
- Choose easier-to-digest formulas. If breastfeeding isn't an option, talk to your pediatrician about switching to a partially broken-down protein formula that may be easier to digest and reduce reflux.
- Dress your baby loosely. Tight pajamas or diapers can make reflux and discomfort worse. Opt for loose, comfortable clothing.
- Keep meals small and frequent. Smaller, more frequent feedings are easier to digest than larger meals and may reduce reflux.
- Avoid overfeeding. Stop feeding when your baby turns away or falls asleep, as overfeeding can make reflux worse.
- Hold your baby upright during and after feeds. Keeping your baby vertical will allow gravity to prevent acid backup.
With some simple lifestyle changes and care, you can help your baby with acid reflux sleep more soundly. Talk to your pediatrician if reflux symptoms persist or disrupt sleep. They may recommend reflux medication to neutralize the acid in your little one's stomach. This will minimize the discomfort of the stomach contents on the esophagus.
Why Baby Reflux is Misunderstood By Many Health Care Providers and Doulas
When my second child was a baby I noticed I had trouble putting her down on her back for sleep periods. She also hated tummy time but she didn't seem to spit up an abnormal amount. After watching her body language and behaviors I realized she was regurgitating contents from her stomach up her digestive track and then swallowing it back down. I also noticed her naps would be interrupted but if I picked her up and burped her, she would settle back down into sleep. I made the conclusion she had silent reflux and that babies with reflux need to be burped more than the average baby.
You can watch my tutorial on my Finesse Over Force Technique here. It's the first step
THE GOOD STUFF is under here.
Traditional medicine will tell you that acid reflux is due to a weak esophageal sphincter. That's a ring of muscle that connects the bottom of the esophagus to the stomach. They'll say the only options are for time to pass for that sphincter to tighten up, trying an incline for sleep, holding them after feeding or using reflux medications which alter the pH of the stomach so that the acid doesn't burn. However, reflux medications have side effects and can also affect the biome of the digestive tract causing gas or discomfort. In addition, don't all babies have weak sphincters? Newborns generally have low tone in most muscles. So then why do some babies have such terrible reflux and yet others are fine? There must be other factors.
The Biggest Cause of Reflux
There's another factor that can make reflux worse - if your baby is swallowing extra air when drinking. This air expands your baby's stomach, causing higher pressure compared to the esophagus. The higher pressure in the stomach pushes on the weak sphincter, forcing it open and allowing stomach contents to regurgitate back into the esophagus.
In silent reflux, the pressure isn't high enough to make the reflux come all the way up and out of the mouth. Instead, the stomach acid and contents regurgitate back into the esophagus, where they can burn and cause pain. But with severe reflux you will have spit up and sometimes projectile vomiting.
The Main Causes of Reflux are:
- Swallowing Air
- Overactive letdown in breastfeeding
- Tongue and Oral Ties
While listed as separate root causes, many of these causes are interrelated.
Swallowing Air
If you can see milk dribbling out, then air is getting in. This is related to your baby's latch on the breast or the bottle. More air in the stomach increases the pressure which increases the regurgitation.
Overactive Letdown in Breastfeeding
Overactive letdown is a common breastfeeding issue where milk ejects from the breast very forcefully and quickly. Here is an overview:
- It occurs when the mother has an excessive milk supply and milk ejection reflex (letdown).
- The reflex causes milk to spray out of the breast, often faster than the baby can swallow. This can cause the baby to choke or pull off the breast or swallow air in the process.
- Symptoms in the baby include gulping, spluttering, coughing during feeds and refusal to re-latch. They may also spit up more often.
- Most babies are able to adapt to a fast flow with time as their oral motor skills improve.
Another way to think about overactive letdown is that it’s like trying to drink out of a fire hose. You are bound to swallow air which can lead to discomfort either in the form of reflux or if that air bubble gets passed into the intestine, gas.
Tongue Ties and Lip Ties (TOTS)
An overactive letdown does not always cause discomfort for the breastfeeding baby. When a baby has proficient tongue mobility and strength, they can adeptly manage the fast milk flow. The baby's tongue acts as a valve to regulate the volume of milk during feedings. However, if the baby's tongue function is impaired due to an oral restriction such as a tongue or lip tie, they may struggle to control the rapid milk ejection. Without the tongue's ability to aptly govern flow, the baby is at risk of gulping excess air while drinking. This disrupted feeding rhythm can understandably cause frustration and unease in the sensitive newborn. Evaluating oral restrictions and supporting tongue mobility are prudent first steps if an overactive letdown results in a distressed, uncomfortable infant. With skilled lactation guidance and any necessary revisions to the baby's oral anatomy, the pair can continue their breastfeeding relationship with diminished difficulty.
A 2017 Study by Ghaheri et al, , concluded that tongue-tie release significantly improved feeding metrics in infants with breastfeeding difficulties, especially those related to oversupply like choking on milk flow.
Summary:
- This was a prospective cohort study that looked at frenotomy (tongue and lip tie release) for infants with breastfeeding difficulties.
- 158 infants were assessed for oral restrictions and underwent frenotomy if significant ties were present.
- Feeding metrics like intake, swallowing, choking, and maternal pain were measured before and after the procedure.
- They found 100% of infants with tongue-tie and 60% of infants with lip-tie improved in their ability to feed after frenotomy.
- For infants with oversupply issues, there were significant improvements in choking/gagging episodes and ability to handle excess milk flow after tongue-tie release.
- The study concluded that tongue-tie release significantly improved feeding metrics in infants with breastfeeding difficulties, especially those related to oversupply like choking on milk flow.
- This provides evidence that tongue-tie can contribute to feeding issues stemming from oversupply, and that frenotomy can improve these symptoms when tongue mobility is restored.
Baby Sleep and Reflux
Reflux in babies can dramatically affect their ability to fall asleep and stay asleep. It will also affect a parent's confidence in how well her baby can sleep which can increase parental interventions at bedtime which can lead to more night waking. Meaning the more you have to help out at bedtime to get your baby to sleep, the more help you’ll have to continue to deliver in the night time.
The drive to sleep is biological, but the way we sleep is a learned habit. All humans wake in the night. Babies who were held, fed or rocked to sleep at bedtime, will ask for this same help when they surface from sleep in the night. To be an independent sleeper, go down without help and sleep 11 + hours through the night, your child needs to be at least 3 months of age and have this important skill.
My second child had “silent reflux” where the stomach contents escaped through a weak esophageal sphincter and splash up into the esophagus or “food tube.” Once the contents are in her mouth she swallowed them back down. She would grimace when this would happen. In the morning when I picked her up from her crib she often had wet spots on her mattress around her head. In the night she would turn in her head and spit the reflux out. But she didn’t cry out or need my help falling back asleep, as her reflux was not severe, and we had worked on independent sleeper from the beginning. Even though she would wake in the night with the reflux, she knew how to relax herself back down into sleep. Her reflux wasn't excruciating and she had the learned skill of falling asleep independently. The learned skill.
In my practice I have worked with many, many babies with reflux that varied from mild to severe. Babies with reflux will need more comfort and care than other babies. They will also sleep through the night later than most kids because of the variable of reflux. This doesn’t mean they will always be terrible sleepers. They just need more time and to get the reflux under control.
5 Tips to Help Your Baby with Reflux Sleep
- Work on your burping technique to get the air bubbles out. Get the tutorial here.
- Move feeding away from sleeping so there's more time to digest and burp.
- Work on the timing of sleeping. You can download my sleep timing chart which outlines how long your baby can comfortably stay awake between naps and bedtime by monthly age.
- Look at your feeding. If you're breastfeeding, do you have a proper latch. And if bottle feeding are you using paced feeding?
- Smaller more frequent feeds can be helpful.
Summary
You can have a “good sleeper.” Don’t lose hope. You first need to get your baby out of pain and diminished signs of reflux before you can completely tackle sleep and have your 4 month and older baby sleeping through the night 11+ hours.
If you need help navigating reflux land, book a 20 minute call to me to see if we're a good fit. Once the reflux is under control and you’re ready to get to the stage where you can put your little one down completely awake without any rocking, bouncing or feeding as part of your routine take a look at my sleep consultations. There’s nothing like having a sleep expert who is also a CLC and who has experience helping parents of babies with reflux guide you through the process.
