Does Thickened Formula Help Reflux?

It’s a timeless recommendation for the spitting baby: put cereal in the bottle and hope to God that things improve. And as a tummy doc in America’s largest children’s hospital, I can attest to the fact that most parents have tried this by the time they reach my clinic. Few, however, report glowing results.

But that’s just me and my simple observation.

But is there any evidence of the effectiveness (or ineffectiveness) of cereal to the baby with reflux? A group of Polish pediatricians performed what we in the business call a ‘meta-analysis’. Essentially what they did was to take all of the research on thickened formula done in recent years and put it together into something of a survey of surveys.

And here’s what they found:

  • Cereal added to formula slightly reduces the daily number of spitting episodes in infancy.
  • Reflux measured using pH probes (a tool for measuring reflux) show little changes when formula is supplemented with cereal.
  • When thickening works, it appears to work well: added cereal appears to increase the number of children with total resolution of their spitting when compared to unsupplemented babies.
  • There isn’t enough information to tell if one thickening agent is better than another.

Bottom line: Adding cereal to your baby’s bottle is unlikely to fix their reflux.

But as I tell my patients, however, it’s worth a shot at 1 teaspoon per ounce of formula (any more than that they’ll suck like the dickens to get the formula from the nipple and swallow lots of air). If the results aren’t impressive during the first 2-3 days, let is go. The hassle and added calories aren’t worth something that isn’t helping. I’ll also add that constipation is a major consequence to cereal supplementation. In this case, recent studies have shown that oatmeal may be a better option.


About Dr. Bryan Vartabedian, gastroenterologist

I am the Director of Community Medicine in the Division of Gastroenterology, Hepatology and Nutrition at Texas Children’s Hospital.
Posted in Nutrition, Parenting

9 Responses to Does Thickened Formula Help Reflux?

  1. Katie says:

    In your opinion, do different formulas make a difference, or does it really depend on what the baby can tolerate?. In my experience, i have given my baby Similac -sensitive and Enfamil A.R -neither has worked completely, my baby still has reflux. She is almost 7 months old

    • DrV says:

      With respect to the management of reflux alone, formula choice should make no difference in symptoms. The evidence for added starch preparations is not strong. While it may not be an option at this point, breast milk may represent the best choice. We always need to keep in mind that protein sensitivity can look just like reflux alone. Depending on a child’s story, this needs to be entertained in the list of potential problems.

      While I can’t comment on the specifics of your child’s care, keep in mind that many infants with reflux are still quite symptomatic at 7 months of age.

  2. Katie says:

    I am sad to see a whole article about formula feeding.

  3. Amber C. says:

    My son had openheart surgery at 9hours old and developed acid reflux and in my opinion the enfamil AR formula worked great! We did one feeding breastmilk,and the nxt formula and it worked for us…maybe it just depends on the sensitivity of the baby?…..

  4. Jo says:

    Thanks for the summary. As a hospital based pediatric nurse for almost 40 years I am often frustrated by feeding orders that include thickening to reduce reflux – including orders for moms to express milk, thicken and bottle feed. I have noticed more and more infants are being labeled with reflux – thickeners, omeprazole and miralax have become almost routine parts of life for seemingly healthy infants – those who are growing well despite spit ups and fussiness. Is that just me or are human GI tracts changing? Aloha, Jo

  5. Sarah Punches says:

    Dr V… I have read your book and it has been enormously helpful! Two quick questions:
    What do you think of using products like “Simply Thick” to thicken breast milk on a bottle in order to avoid the constipation issue with cereal? My son is 10 weeks old and has reflux and spits up so much that it disrupts sleep…. Rice cereal made him constipated.

    He is also on the compounded liquid Prevacid. I read on an old blog post of yours that the purple streaks seen in spit up is from the Prevacid. I just wanted to confirm this is correct, as my son does have occasional purple bits in spit up! At first I though it was odd colored blood until I read your post. My doc knew nothing about this… So wanted to check with you!
    Thank you!

  6. courtney clinton says:

    Kellan was born full-term via c-section weighing 6 lb., 7 oz and 19 inches in Phoenix. Right away, I knew something was wrong, his cry was weak and he could barely open his mouth. His jaw was recessed. He spent the next night with me and failed to breast feed. He seemed to be very lethargic and did not want to eat. He spent the next week in NICU on an IV. He saw a craneofacial specialist and he ruled out Pierre Robin Syndrom and told us he had a high/cavernous palate. With some success taking the bottle we were sent home only to return to the hospital 3 weeks later for failure to thrive. He was hospitalized for a week, saw a ped. cardiologist who said he was fine with a small murmur. We got him to eat a little more, gain a little weight, went home only to return to the hospital 2 more times with a month in between each time for FTT. The last time he was hospitalized we were told he had reflux, silent reflux, aspirating, low-tone, laryngomalacia and dysphagia. He was put on an NG tube at 3 1/2 months, then a NJ tube, then back to the NG tube and finally had the G-tube placed at 9 months. With numerous swallow studies, blood tests, bronchoscopy, Upper GI, endoscopy, a trip to the ENT, an allergist and constant weight checks, we have not found anything “wrong.” He has been in feeding therapy, physical therapy and occupational therapy and I have not found that to be helpful. Before we left Phoenix in January, Kellan was accepted into an intensive feeding therapy program at Phoenix Children’s hospital. This helped get him eating a little. Unfortunately the last week of his therapy he had the flu and regressed a couple weeks and we moved to the Thousand Oaks area. Here, it has taken me months to get him into therapy. We are currently in physical, speech and occupational, but again, I find this to be little help. We have been through a couple of GI’s, and just found one we think we like. He has ordered blood tests that were taken last week and we have given him some of his stool samples. I also have bugged Children’s Hospital of Orange County enough that we have an appointment to get him evaluated for their feeding therapy program on July 21-24.

    If you have any suggestions, I would appreciate them and any other thoughts and feedback you may have.

  7. Caiping SU says:

    Dr. Vartabedian,
    My son was born on Feb. 13. He was diagnosed with GERD and milk protein allergy. He was breastfed for 2 months, then EleCare alone to manage his inflammation. But his reflux somehow is worse, exactly as those crying babies in your Colic Solved book. I went on a total elimination diet for 2 weeks and tried breast milk. No allergic reaction this time and he slept through the nights when I breastfed, but there is quite some green mucus in his poop. Does that mean he still can’t digest protein in breast milk? Should I not give him breast milk yet? Or can I breastfeed him once in the evening to cope with his evening crying hours? I’ll really appreciate your expert opinion on it. I can’t get answers with my resource at hands and felt helpless.

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