Hi Dr Chilton,
My 8 week old daughter is very unsettled and I believe she has reflux. I also have a 2yo and 4yo so know that all babies cry and they are all different. After a number of weeks of closely observing my baby (who is in the bed with me at night) I am sure she is in pain after feeds and being woken up by pain. My GP is very supportive and we have started her on Losec. I saw our paediatrician today (who I will never see again) and he said she has reflux (based on crusty milk around her nose), but it is not causing her pain. According to him, she is struggling to digest my breastmilk and we should switch to formula. My baby has been slow to gain weight so we added in 120ml of formula at 5pm and she is now gaining 150-200g/week. The paediatrician’s words were “I don’t know why everyone makes such a big deal about breastfeeding, formula is easier for everyone”. I came home quite upset as my milk supply is good and I want to keep breastfeeding. What are your views on reflux and unsettled babies and breastfeeding? Thanks so much! Laura

Your baby almost certainly has reflux – because pretty well all babies do. Somebody did a study of how much stomach acid entered the oesophagus in normal babies and found that ON AVERAGE babies have about 22 episodes of reflux every 24 hours! The crusty milk around her nose tells us nothing of value. But the question is: does she have ‘Reflux Disease’?  She might, but it’s not the first and most likely explanation.

The most important factor here is her weight gain. It’s not enough, and if it is below 150g/week, which it was before the formula, then that’s enough to make her unsettled and ’in pain’.

While we’re on the subject – all unsettled babies look like they’re ‘in pain’. To a baby pain, stress, or other things that are not right in their life, creates the ‘stress response’. They draw their knees up, wrinkle up their faces and howl. Same stress hormones, same effect on the baby. They can’t differentiate. It’s a survival response for a helpless baby. So just because they look like they have excruciating abdominal pain doesn’t mean that they do, and for a breastfed baby, it is doubly unlikely.

Back to the weight gain. You say you have an adequate milk supply but I would suggest you see a Lactation Consultant to confirm that, and check that she’s latching well to the breast. The fact that she took the extra formula feeds suggests that she is hungry. Did the unsettledness improve after the formula feed? If so, that’s the diagnosis. Go see an LC.

Meanwhile, Gastro-Oesophageal Reflux Disease (GORD) in babies tends to occur in those babies that vomit a lot. This is a slide from one of my recent lectures.


  • No relationship between crying duration and GOR
  • No relationship between Fractional Reflux Time (i.e. the %age of time there is acid in the gullet) and irritability
  • Silent reflux did not occur < 3 months

Reflux predictors

  • Vomiting X 5 times + daily
  • Feeding difficulties / refusal
  • Poor Weight gain
  • Blood in vomit

ref: (Heine RG et al J Paediatr Child Health 2006;42:134-139)        (Dr Heine is a paediatric gastroenterologist at Melbourne Children’s Hospital.)

So this doesn’t sound like her, does it?..

It is also unlikely that she has the other commonly made (and usually wrong) diagnosis of Cow’s Milk Protein Allergy. Especially if she took the formula well and it did not make her worse, as there is a lot more CMP in formula than there is in breastmilk.

Regarding you paediatrician’s view regarding ‘struggling to digest your breastmilk’, he must be speaking in code for ‘there isn’t enough breastmilk, give her formula’. He is then trying to comfort you by suggesting that formula’s just as good. His heart is in the right place, but he is bending the truth to help you accept what he believes is best for you and your baby.

Of course it is a rare baby that struggles to digest breastmilk.

  • 3 – 7% of babies are sensitive to cow’s milk protein and there is a tiny bit excreted into human breastmilk. However most of these allergic babies are getting the massive amount in formula
  • After a bout of gastro-enteritis babies can have trouble absorbing the lactose in the milk. They become lactose intolerant and it gives them bloating and diarrhoea. It is incredibly rare to be born with lactose intolerance (and they are mostly Fins or Russians)


Neither of which is relevant here.

There is no question at all about breastfeeding being totally right in so many ways and on so many levels for all babies. Formula is just food, but breastmilk is so much more and confers lifelong benefits to both mother and baby, not only to their bodies but to their minds. But we are all (health professionals included) a product of our culture and our culture is somewhat confused about this, due to the marketing power of the formula companies and the need for women to get back in to the workforce too soon.

Now to unsettled babies.

Your daughter has two excited siblings who probably can’t get enough of her (though the 2 year old might have had enough…).This means the household might be a very busy place at the moment and babies between 4 and 12 weeks old are not very appreciative of so much activity.

For more on this subject go to my website and read my article  “Bore Your baby to Sleep” which might be relevant.

But I emphasise, until you’ve got the weight gain under control (aim for 200g/week), this alone is enough to upset her.

Let us know how you get on.