Silent Reflux in Babies: Signs, Symptoms & When to Seek Help

By Dr. Jennifer Harris

If your baby seems uncomfortable during or after feeds but rarely spits up, you may have wondered whether silent reflux could be the reason.

Perhaps your baby arches their back, pulls away from feeds, coughs or clears their throat, seems uncomfortable when laid flat, or wants to eat but repeatedly stops after taking only a small amount.

Parents are sometimes told that reflux cannot be the problem because their baby isn't visibly spitting up.

But reflux doesn't always come with obvious vomiting or spit-up.

What is silent reflux in babies?

Gastroesophageal reflux occurs when the contents of the stomach travel backwards into the esophagus (the tube connecting the mouth to the stomach).

Reflux itself is extremely common during infancy. Babies have a liquid diet, spend significant amounts of time lying down, and their digestive system is still developing. Many healthy babies therefore spit up frequently without being particularly bothered by it.

With so-called silent reflux, however, stomach contents travel upward into the esophagus and are then swallowed again rather than coming out of the baby's mouth.

That's why parents may see very little spit-up despite noticing behaviours that suggest their baby is uncomfortable.

The term "silent reflux" can also be confusing. It isn't necessarily a completely separate condition from gastroesophageal reflux—it describes a pattern in which reflux isn't readily visible.

And importantly, the symptoms commonly attributed to silent reflux can have other causes. A baby's overall feeding, growth, respiratory symptoms and medical history all need to be considered.

What are the possible signs of silent reflux?

Every baby presents differently, and no single symptom proves that a baby has reflux.

However, parents may report behaviours such as:

• Arching or appearing uncomfortable during or after feeds

• Pulling away repeatedly while feeding

• Crying or becoming distressed during feeds

• Frequent swallowing or gulping when not actively eating

• Hiccups

• Coughing or throat clearing

• Hoarseness or a raspy cry

• Appearing uncomfortable when placed flat after feeding

• Frequent waking or difficulty settling

• Wanting to feed but stopping shortly after beginning

• Refusing the breast or bottle

• Feeding more successfully when sleepy or asleep

  
  

Some babies may also experience visible spit-up alongside these symptoms. "Silent" doesn't necessarily mean that a baby never spits up.

If my baby isn't spitting up, can reflux really be the problem?

Yes, reflux can occur without large amounts of visible spit-up.

What comes out of your baby's mouth doesn't necessarily tell us everything that's happening inside their esophagus.

At the same time, it is important not to assume that every unsettled baby who doesn't spit up has silent reflux.

Crying, arching, coughing, feeding refusal and disrupted sleep can occur for many different reasons. That's why I prefer to look at the whole baby, rather than diagnosing reflux from one symptom alone.

What's the difference between reflux and GERD?

This is an important distinction.

Gastroesophageal reflux (GER) describes stomach contents moving back into the esophagus. This is common during infancy and can happen in otherwise happy, healthy babies.

Gastroesophageal reflux disease (GERD) is different. GERD is considered when reflux is associated with troublesome symptoms or complications.

In other words, the presence of reflux itself isn't necessarily the problem.

The question is:

How is this affecting the baby?

A baby who spits up frequently but feeds comfortably, grows appropriately and seems generally content is very different from a baby who rarely spits up but cries through feeds, repeatedly refuses to eat or appears to associate feeding with pain.

Visible spit-up is only one piece of the picture.

Why does my baby seem hungry but then pull away from the bottle or breast?

This is one of the patterns I pay particular attention to.

Parents will often describe a baby who clearly shows hunger cues and eagerly accepts the breast or bottle, only to pull away, arch, cry or refuse shortly after the feeding begins.

Sometimes they'll try again because they're still hungry—and the same thing happens.

There are several possible reasons for this pattern, and reflux-related discomfort is one of them.

If feeding repeatedly causes discomfort, babies can also begin to learn that eating predicts something unpleasant.

Over time, what started as a medical or physical problem can therefore develop a behavioural component as well.

A baby might:

Feel hungry → begin feeding → experience discomfort → stop → become hungry again → try to feed → experience discomfort again.

Eventually, some babies begin reacting before the discomfort has even occurred because they have learned to anticipate it.

This is one pathway through which feeding aversion can develop.

It is one reason I don't like to dismiss persistent feeding refusal simply because a baby is still gaining weight.

Why will some babies with feeding difficulties eat when they're asleep?

Another pattern parents frequently describe is: "My baby refuses the bottle while awake but drinks perfectly when sleepy." This deserves attention.

When babies are drowsy, their behavioural response to feeding may be different, which can sometimes make feeding easier.

Parents understandably begin timing feeds around naps or feeding their baby while asleep because it feels like the only way to get enough milk into them.

However, if your baby consistently needs to be sleepy or asleep in order to feed, it is worth discussing this with your pediatrician or feeding professional.

We want to understand why awake feeding has become difficult, rather than simply finding increasingly elaborate ways around the refusal.

Could something other than reflux be causing these symptoms?

Absolutely.

Many symptoms associated with reflux are non-specific, meaning they can occur with several different conditions. Depending on the baby's particular symptoms and history, a clinician may need to consider other possibilities, including:

• Cow's milk protein allergy or other food-related reactions

• Feeding or swallowing difficulties

• Flow-rate or bottle-feeding issues

• Oral-motor difficulties

• Airway conditions

• Constipation or other gastrointestinal discomfort

• Feeding aversion

• Other medical causes of pain or distress

  
  

Sometimes more than one factor is present.

For example, a baby may initially experience discomfort from reflux but later develop feeding avoidance because feeding has repeatedly been associated with that discomfort.

This is why simply asking, "Does this baby have reflux?" isn't always enough.

We also need to ask:

Why is this baby uncomfortable? Why has feeding become difficult? And what is maintaining the problem now?

Does every baby with silent reflux need medication?

No.

Reflux is extremely common during infancy, and acid-suppressing medication isn't appropriate for every baby who spits up, cries or seems unsettled.Treatment should be individualized based on the baby's symptoms, feeding history, growth, medical history and clinical assessment.

For babies who have already been prescribed reflux medication but are continuing to struggle, it may be appropriate for their healthcare provider to review the treatment plan. This can include looking at whether the medication is still appropriate, whether the dose remains suitable as the baby grows, how and when the medication is being given, and whether a different treatment option might be more appropriate for that particular child.

Babies grow quickly, and a medication plan that was appropriate several weeks or months ago may need to be reassessed. Different medications also work in different ways, so simply saying that a baby has "tried reflux medication" doesn't always tell us whether their reflux has been adequately managed.

Importantly, the goal is not to give babies more medication.

The goal is to use medication thoughtfully, appropriately and effectively when it is clinically indicated, while continually considering whether it is still needed and whether we're treating the right problem in the first place.

If symptoms persist despite treatment, that is an opportunity to step back and look at the whole picture. Does the diagnosis still make sense? Is the current medication and dose appropriate? Could something else be contributing to the baby's discomfort? Has an initial painful feeding experience begun to affect feeding behaviour?

Sometimes optimizing an existing treatment plan is appropriate. Sometimes another medication may be a better option. And sometimes the answer isn't reflux medication at all. Parents should always speak with their baby's prescribing clinician before stopping, increasing, decreasing or changing reflux medication.

When should I seek medical advice?

Speak with your baby's healthcare provider if you are concerned about persistent reflux symptoms, particularly when they are interfering with feeding or your baby's wellbeing.

Seek medical attention promptly for concerning symptoms such as:

• Difficulty breathing

• Blue, grey or unusually pale colour

• Repeated choking or significant difficulty during feeds

• Blood in vomit

• Green or bile-stained vomiting

• Forceful or persistent vomiting

• Signs of dehydration

• Significant lethargy or a baby who is unusually difficult to wake

• Poor weight gain or weight loss

• Persistent feeding refusal or a substantial reduction in intake

  
  

If something about your baby's condition feels acutely wrong, seek urgent medical assessment rather than assuming reflux is responsible.

Weight gain isn't the only thing that matters

One misconception I encounter frequently is that if a baby is gaining weight, their reflux or feeding difficulty cannot be significant. Growth is incredibly important—but it isn't the only measure of feeding health. Some babies maintain their growth because their parents are working extraordinarily hard to get every ounce into them.

Parents may spend much of the day offering feeds, walking and bouncing while feeding, distracting their baby, feeding during naps, or waking repeatedly overnight because those are the only times the baby will eat.The number on the scale doesn't necessarily capture that experience.

I want to know not only whether a baby is growing, but also:

Are they comfortable?

Can they eat while awake?

Do they appear to enjoy feeding?

Does feeding feel manageable for the family?

Is the baby developing increasingly restrictive feeding behaviours?

Those questions matter too.

When reflux is more than "just something babies do"

Most babies experience some degree of reflux, and many improve naturally as they grow.But "reflux is common" and "your baby's symptoms don't matter" are not the same statement.

If your baby appears to be in pain, is increasingly refusing feeds, is coughing or choking during feeds, is struggling to gain weight, or can only be fed through increasingly complicated strategies, it is reasonable to ask for a closer evaluation.

The goal shouldn't simply be to stop visible spit-up.

The goal is to understand why your baby is struggling and what they need in order to feed comfortably and safely.

Need Help With Your Baby's Reflux?

At Crying, Colic & Beyond, we work with families dealing with persistent reflux, colic, feeding difficulties and other complex infant feeding concerns.

Our telehealth consultations allow us to take a detailed look at your baby's symptoms, feeding history, previous treatments and the bigger clinical picture to help determine appropriate next steps.

Learn more about our Reflux & Colic Consultation →

About Dr. Jennifer Harris

Dr. Jennifer Harris is a board-certified pediatrician with extensive experience working with babies and children experiencing reflux, gastrointestinal symptoms, feeding difficulties and feeding aversion. Through Crying, Colic & Beyond, she works with families via telehealth to better understand the factors contributing to their child's symptoms and feeding challenges.

This article is intended for general educational purposes only and does not constitute medical advice, diagnosis or treatment. Always discuss concerns about your baby's health, feeding or medication with an appropriately qualified healthcare professional.