February 9, 2024

Tears before bedtime? Silent reflux in babies

By Nicky Barker

Reflux is often bandied about in mothers groups and parent circles when a baby seems like they’re in discomfort, or are spilling up loads and loads 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 food. Ouch!

As adults this is commonly known as ‘heartburn’ and although the reasons for heartburn in an adult can be quite different to infant reflux, the results are the same - that horrid burning sensation of acid coming up your oesophagus and even into your mouth.

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

Check out our blog 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.

For now though, we want to touch specifically on silent reflux (also known as laryngopharyngeal reflux or LPR), as this can be harder to spot than general reflux, and may be affecting your baby’s ability to sleep (amongst other things).

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.

Because you don’t see your little one actively spewing up, the symptoms aren't always obvious, hence the terminology ‘silent’.

Not knowing what’s causing your little one pain can be extremely heart wrenching. You may second guess your every move as a parent or caregiver, and wonder when oh when you will have a “normal”, more settled baby, and not feel at your wits end.

Symptoms of silent reflux

Crying (and crying and crying and crying…)

Tears, perhaps better described as screams, are your baby’s way of telling you they’re in discomfort, however a lot of babies with reflux won’t cry, instead they may be difficult 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 bubs is on the boob or bottle, there will likely be some feeding issues for an infant with silent reflux.

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

Or some reflux babies will “snack” a lot, either because feeding hurts and they keep stopping, or because more milk going down and pushing acid back downwards is soothing. They may also have problems 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 bandied about 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’ll often take ages to settle to sleep, and once asleep, may wake up after a small window of a few minutes, often screaming rather 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 loss of weight)
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 it's a good idea to write down as many of the signs listed above that your baby may have.

Babies who have reflux are often very happy when distracted and people, including doctors, may not believe that 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 is crying loads and is generally irritable, but doesn’t seem to suffer from any of the other silent reflux symptoms we’ve mentioned, it’s essential to consider that your baby could actually be over or undertired, 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.

The only way to truly rule out overtiredness, under tiredness and overstimulation is to have your baby sleeping as well as they possibly can for their age. Our age-specific Sleep Programs can give you a helping hand here.

Then, if your baby is still not sleeping after trying our Sleep Programs, 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

Keep your baby as upright as possible when they’re awake, which makes sense given that you don’t want liquid to come 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 immediately after feeding, the bumping around in a laid back position will not help
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.

But you may start to notice a pattern that certain foods are causing discomfort in your baby, such as coffee, chocolate and citrus fruits, these foods may be causing your babies reflux to be worse.

Less commonly if your baby has reflux caused by an intolerance rather than the most common type of reflux, which is caused by an immature valve, the most common culprits are dairy, soy and wheat.

Do be careful though - as a breastfeeding mother you require lots of nutrients, so we’d recommend talking to your doctor before making any dietary changes.

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 a fine balance of helping your baby feel comfortable and alleviate his pain, while also trying to avoid any negative sleep associations that may mess with his ability to sleep later on.

We strongly recommend that you don’t launch into a “cry it out” style form of sleep training when your baby or child has diagnosed silent reflux.

We believe that a more gentle approach is required. Babies actually thrive on routine and for babies with silent reflux or other medical conditions, getting their sleep on track will help you identify if the reflux returns or flares up.

Our Programs take into consideration babies with reflux, and can offer tips to help get your little one self settling faster, with ease.

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 prescribed medications don’t work, your doctor may consider getting you tested for allergies, or refer you to a gastro specialist to investigate things “internally” with more invasive studies as mentioned above.

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 fabulous to be able to give you a definitive list of foods that are well tolerated by reflux babies, but of course, when it comes to reflux, every baby is just too different.

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 notice that signs of reflux are gone when their babies are able to sit up by themselves or walk, or when they start to eat solids.

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 Programs.

If you need some further help with your baby or toddler's sleep triggers, we've got all the information you need to implement positive change in our comprehensive, holistic, evidence-based Sleep Programs .

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References:

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

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