Silent reflux in babies, also known as laryngopharyngeal reflux (LPR), is subtle. Unlike typical infant reflux that often involves visible spit-up or vomiting, silent reflux occurs when stomach contents travel up the esophagus but are re-swallowed. This common condition can cause discomfort and irritation for infants.
Understanding Silent Reflux
Silent reflux involves the backward flow of stomach acid and enzymes into the esophagus, reaching the throat and voice box. While gastroesophageal reflux (GER) in infants is common and often involves spitting up, LPR is “silent” because the refluxed material is re-swallowed. The irritation from these stomach contents can affect sensitive tissues in the upper airway, including the larynx, oropharynx, and nasopharynx. This differs from gastroesophageal reflux disease (GERD), which primarily irritates the esophagus and is often associated with heartburn. While both are forms of acid reflux, LPR symptoms are distinct and can sometimes mimic other conditions like colds or allergies.
Recognizing the Signs
Identifying silent reflux is difficult due to its subtle symptoms. Parents might observe frequent back arching during or after feedings, indicating discomfort. Unexplained irritability, fussiness, or crying, particularly after feeds, are also common indicators.
Babies may exhibit feeding difficulties: pulling away from the breast or bottle, refusing to eat, or crying during feeds. Other signs include chronic congestion, frequent swallowing or gulping sounds after feeding or burping, hoarseness, voice changes, and persistent coughing without other illness symptoms. Recurrent ear infections, noisy breathing, gagging, or poor weight gain despite no visible spit-up can also point to silent reflux.
Causes and Contributing Factors
Several physiological factors contribute to silent reflux. One reason is the immaturity of the lower esophageal sphincter (LES), the muscle ring that normally closes to keep stomach contents down. This muscle may not be fully developed in infants, especially premature ones, allowing stomach contents to flow back up. The upper esophageal sphincter (UES) can also be immature, allowing acidic fluid to reach the throat and nasal passages.
Additionally, infants spend much time lying flat, reducing gravity’s assistance in keeping food in the stomach. Their almost entirely liquid diet also makes regurgitation easier compared to solid foods. Overfeeding, which puts pressure on the LES, can also contribute to reflux. Certain foods in a breastfeeding mother’s diet, such as dairy or eggs, might trigger symptoms in sensitive infants; eliminating these for a few weeks may help.
Diagnosis and Management
Diagnosing silent reflux in infants often relies on a pediatrician’s review of symptoms and a physical examination, as no definitive test exists. If symptoms suggest a complication or another health problem, a doctor might recommend tests such as an upper gastrointestinal endoscopy, esophageal pH monitoring, or X-rays. Lifestyle and feeding adjustments are typically the first line of management. Strategies include:
Offering smaller, more frequent feedings to reduce milk volume and lessen reflux.
Keeping the baby upright during feeding and for at least 30 minutes afterward to aid gravity.
Frequent burping during feeds to release trapped air.
For bottle-feeding, ensuring the nipple is full of milk and using a slow-flow nipple to minimize swallowed air.
For breastfeeding mothers, eliminating potential trigger foods like dairy, soy, or eggs from their diet for two to four weeks.
Elevating the head of the baby’s crib or bassinet slightly, under medical guidance.
Medical intervention, such as antacids, H2 blockers (like famotidine), or proton pump inhibitors (PPIs like omeprazole), may be considered if lifestyle changes are insufficient and the baby has poor weight gain, feeding refusal, or a swollen esophagus.