Reflux in Preemies

Why premature babies get reflux and what you can do about it

Stomach Illustration

Many preemie babies are diagnosed, either during their NICU stay or after, with gastroesophageal reflux (GER), otherwise known simply as reflux. Many preemies have this condition, so let’s take a look at what’s involved, what to expect, and what can be done about it.

What Is Reflux?

Reflux happens when the contents of a baby's stomach don't stay in the stomach, but instead, come up into the esophagus (the tube connecting the mouth to the stomach) in small amounts or large amounts, sometimes visible as spit up or vomiting.

Everyone has a muscle at the top of their stomach — called the esophageal sphincter – which naturally opens and closes to allow swallowing, burping, and vomiting, and its job is to keep milk, food, & stomach acid in the stomach. When the stomach acid and partially digested food & liquids push back up through that sphincter into the esophagus, it’s called reflux.

Everyone experiences some mild forms of reflux. But that acid is hard on the tissue of the esophagus, and when it happens so often that it causes irritation and damage to the esophagus, that’s when the condition of GER is present.

Why Are Preemies More Likely to Get Reflux?

Preemies are more susceptible to reflux for two main reasons:

First, preemies have underdeveloped muscles and weaker muscle tone than full-term babies, and that's true even in their esophageal sphincter muscle. Because of this weakness, the sphincter isn't strong enough to stop stomach contents from flowing back up into the esophagus.

Another reason preemies are more prone to reflux is because preemies often have respiratory distress. When preemies breathe abnormally (breathing faster or harder) because of lung disease, the muscles near the top of the stomach can be affected, stretching the esophageal sphincter and causing it to remain open.

Because of these two factors, stomach acid, and undigested foods are allowed out of the stomach, up into the esophagus and that causes irritation. Our bodies can handle the occasional bit of burped up stomach content, but when it happens frequently, day in and day out, the acid irritates the tissue of the esophagus, making it inflamed and painful.

The Difference Between Mild and Severe Reflux

Mild reflux is pretty easy to manage. Other than getting good at burping your baby and carrying plenty of burp cloths with you everywhere, your life may not be affected terribly by reflux. Your baby will still grow well and feel fairly comfortable.

But more serious GER can cause many difficult and unpleasant experiences with your baby, such as:

  • profound fussiness - during feedings and/or in between feedings
  • refusing to eat, or only taking very small feedings
  • frequent and/or large spit ups
  • choking during feedings
  • apnea & bradycardia during and after feedings
  • blood in the stool
  • frequent coughs and infections
  • insufficient weight gain

If your baby is diagnosed with GERD while still in the NICU, you have your NICU professionals to talk with about strategies for making it better. They can try positioning your baby differently, altering feedings, medications and more.

If you are already home with your preemie, you may be feeling confused and alone about what to do. You may not even know if your baby actually has reflux.

So if your preemie at home seems extremely fussy, particularly during feedings or with noticeable spitting up, the most important first step is to talk to your pediatrician about it.

Treatment for Reflux in Preemies

Anything that will keep stomach contents down in the stomach, and not up in the esophagus, is the goal. Once the stomach contents stay where they belong, the irritated tissues can begin to heal and everyone can feel better.

Any of these treatments will take time to work because they work by allowing the damaged and painful tissue to heal. Your baby won't feel noticeably better until that tissue heals, and that takes time (days or even weeks). Be patient.

Many options exist, ranging from simple to complex. These include:

Upright Position

Babies are supposed to be lying flat on their backs for best SIDS prevention, but they have gravity working against them. It’s much easier for milk to leak out of the stomach in that flat position. Babies in car seats may have an even harder time, because the car seat places increased pressure on the tummy, making reflux even more likely.

Many pediatricians recommend keeping your baby in an upright position as much as possible, particularly after feedings. This can be accomplished by holding your baby upright after feedings. When your baby needs more time upright than you can do in your arms, consider using a safe & effective wedge like the Res-Q Wedge (for use in the NICU or at home) which keeps baby safely upright and lets gravity help your baby.

Frequent Burping & Pacifier Use

Parents are advised to burp frequently during a feeding in order to keep as much air out of the stomach as possible so that big burps don’t bring up large amounts of stomach contents.

Parents also find that babies who suck on pacifiers often throughout the day, especially after feedings, keep the swallowing motion and esophagus moving in the right direction, keeping stomach contents in place.

Thickening Feedings

Sometimes, parents are advised to use thickening agents such as rice cereal added to milk, with the reason being that thicker milks and foods have a harder time getting up and out of the stomach. However, this practice is being used less often these days (see the American Academy of Pediatrics warning here).

Definitely, do not try this without talking first with your pediatrician. Thickeners can cause great stomach upset if used improperly. But with proper guidance, some parents have had success with improving reflux symptoms.

Changing a Breastfeeding Mother's Diet, or Changing Formula

Many times reflux is related to a baby not tolerating certain proteins in their milk. Mothers who are breastfeeding their preemie with reflux may well be advised to eliminate some common problem foods such as dairy, eggs, soy or certain meats. Try an elimination diet or seek the help of a lactation consultant. 

When preemies with reflux are fed formula, the same thing may be true — something in the formula may be triggering the poor digestion or irritating your baby's tummy. A new formula may be the answer. Always check with your pediatrician before switching formulas, however. Preemies usually require specialized formulas, so you should not just switch until you get the green light from your doctor.

Reflux Medications

Your baby's doctor may prescribe medications to help, but it's always wise to try the non-medical interventions, listed above, first. Medications usually prescribed for GER in infants work by changing the acidity of the stomach contents, making it less acidic. That means the reflux is still happening, it's just not as damaging to the esophagus.

However, the acidity of our stomachs is for good reason — the acid in our stomachs helps kill bacteria. So by using medications for reflux, babies may be at greater risk for infections. So, it can be a wonderful solution, if none of the other strategies work, but be prepared for them to take many days or even weeks to be effective.

Reflux Surgery

Surgery is usually only required when a baby's reflux is so severe that it prevents adequate weight gain or it causes breathing complications.   

Babies with reflux are extremely irritable, and who can blame them? They hurt! To make it worse, the very thing that should be most comforting to them — feeding — is what hurts them the most. So they’re in pain and frustrated.

This means parents are frustrated too. It is hard to care for an irritable baby. Please be sure to take care of yourself, and don’t feel bad for needing to do so. Your baby needs you to keep your mental health as good as possible, so finding a friend to watch the baby while you take a break can work wonders. Talking to other parents can, too.

And remember that your baby is not a bad baby, but a hurting baby may help. She’s not trying to make your life miserable by having reflux any more than you’re trying to make her life miserable by feeding her. Try to get the reflux under control with the help of your pediatrician, and take good care of yourself!

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