Breast fed babies can be given an alginate thickener before feeds, and bottle feeds can be thickened with a preparation based on rice starch, corn starch, locust bean gum or carob bean gum. In terms of treatment benefit, the use of alginate in one trial reduced the median number of vomiting episodes per day from 8.5 to 3, while the placebo group reduced from 7 to 5, giving a median treatment benefit of 3 vomiting episodes per day. The research has mostly not measured crying/ unsettled episodes, which are usually the parents’ main problem or concern.
A small amount of reflux, regurgitation or posseting is very common in small babies and does not need treatment. More serious reflux can cause pain, poor growth, or oesophageal ulceration.
Infant reflux, which may present as irritability, recurrent vomiting, or refusal to feed.
Onset of regurgitation after the age of 6 months suggests another diagnosis.
A 2017 Cochrane review of 8 trials in 637 full term babies found no major harms. However, there have been reports of necrotising enterocolitis in premature babies given xanthan gum or carob gum thickeners.
Many products are available over the counter. Alginate is marketed as “Gaviscon Infant”.
Research using pH monitoring showed feed thickeners were effective at reducing the hours of the day with pH less than 4. This may explain how feed thickeners can reduce pain. A minority of trials reported whether infants were less irritable, with mixed results. Two of three trials that reported sleep disturbance showed no benefit.
Tips and challenges
Reflux without vomiting or “silent reflux” is an unlikely cause of infant crying.
- Before going to thickened feeds, try a period of smaller and more frequent feeds.
- In bottle fed babies try a cereal thickener before stepping up to use of an alginate.
- Alginate thickener should be trialled for 1–2 weeks and only continued if effective. If effective, try stopping it every month as the problem will often have resolved. The research shows it can be effective and is safe, so parents will be able to rapidly report if it works for their child.
NHRMC Level 1 evidence.