Separating Fact from Fiction in Pediatric Medicine: Burping Doesn’t Prevent SIDS, and Other Gas Related Nonsense
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We often write posts about very serious topics here on SBM. Some readers may not believe that this is going to be one of them, and they might be correct depending on their threshold for seriousness. What I’m going to discuss today certainly isn’t causing widespread suffering in the world, and it isn’t at all related to vaccine hesitancy or the SARS-CoV-2 pandemic, but that doesn’t mean that it isn’t important to many caregivers of young infants. And if it’s important to them, it’s important to me.

As a pediatric hospitalist that primarily takes care of newborns, the subject of burping comes up frequently. Most parents, from the new and nervous to the seasoned veterans of baby wrangling, take part in this particular example of medical folklore every time that they feed their baby. They calmly hold the child and tap or rub their back until they hear a noise that they label a burp, and then, satisfied with their active role in the proper order of the universe, they gently put the baby down for a nice nap. Maybe they even get some sleep themselves. It doesn’t always go down like this, however.

Most parents don’t ask me about burping their baby. They just do it and everything goes well. We have been told by society, medical professionals, friends, family, and pretty much anyone else you can think of that this is a normal and necessary thing to do. Maybe more parents question the practice than I’m aware of and just don’t say anything, perhaps wishing to avoid the shocked responses and potential shame they might feel should their reckless parenting choices be revealed.

I do tend to hear from the parents who want to burp their baby but are concerned that they are doing it wrong. Are they patting the baby’s back to hard? Could they injure their precious bundle of joy during a session of overzealous burping? I also hear from parents who are anxious whenever their baby doesn’t burp after a feed. Will they spit up and choke during sleep? Will their baby have reflux? Will they have excess gas in their tummy and be in pain? I’ve known many caregivers to spend inordinate amounts of time during and after feeds trying to get even the tiniest little burp out.

I get these questions a lot and sometimes do wonder about the origins of their worry. It’s all those sources I mentioned above of course, but I mean the origin of baby burping itself. Unfortunately, I have been unable to ever find a reliable resource discussing the history of this practice. This paper on the history of infant feeding is quite interesting but does not even mention burping or even tummy gas. I also cannot find any helpful discussion of the prevalence of baby burping across cultures, but my assumption has always been that it is a widespread phenomenon. I meet caregivers from all over the world practicing in the Boston area, and burping is fairly ubiquitous.

So why am I writing about this topic today? Because of the wiggle butt of course. What? You haven’t heard of the wiggle butt? Don’t feel bad. I don’t watch the TikToks either, but someone on Twitter was nice enough to bring the video, which has now been viewed many millions of times, to my attention. The technique, which is chiropractor approved, is nothing special. And sure, it “works”. I’ve never argued that jostling a kid around a bit doesn’t increase the possibility of them burping after a feed, only that caregivers don’t need to do it and that there is no proven benefit. More on that shortly.

So I watched the wiggle butt video and then started watching other videos on burping, like the one I linked to above from the chiropractor who sounds like he was in the cast of The Crown. And it’s about as medically accurate as that show is historically accurate. But I’m fairly confident that it’s the video that inspired the wiggle butt mom. I then started reading what medical doctors and fancy academic research centers have to say about burping and found that in many cases it isn’t any better than the information promoted on chiropractic websites. Then I really got into the weeds.

But first, what’s the deal with burping? Why do we do it? Is there any evidence to support the practice?

WTB? (What the Burp?)

Parents are almost always advised to burp their babies by pediatricians and other pediatric healthcare providers. The AAP even recommends it to reduce episodes of reflux or “spitting up“:

Extra gas in your baby’s stomach has a way of stirring up trouble. As gas bubbles escape, they have an annoying tendency to bring the rest of the stomach’s contents up with them. To minimize the chances of this happening, burp not only after, but also during meals.

Where do these tummy bubbles come from? As opposed to rectal gas that exits as flatulence, which is primarily composed of byproducts of intestinal bacterial fermentation, any gas in the stomach of a baby consists of air swallowed during feeding unless they are being fed a carbonated beverage. This swallowed air supposedly becomes trapped in the stomach, resulting in discomfort, and it increases the likelihood that a baby will spit up or develop reflux disease.

Parents are frequently advised to burp after every feed. If a parent seeks guidance because of suspected GI issues, they may get advice such as these recommendations from Johns Hopkins All Children’s Hospital:

Try burping your baby every ounce during bottle-feeding or every 5 minutes during breastfeeding if your baby:

  • tends to be gassy
  • spits a lot
  • has gastroesophageal reflux disease (GERD)
  • seems fussy during feeding

If your baby doesn’t burp after a few minutes, change the baby’s position and try burping for another few minutes before feeding again. Always burp your baby when feeding time is over.

The problem with this advice, other than that it results in feeds taking an hour or more and a mother who never gets any sleep, is that the belief it is based on has never been anything more than conjecture. Again, it does not appear that anyone knows where, when, or why this focus on tummy gas problems started. If I had to hazard a guess, baby burping behaviors preceded our attempts/ability to come up with a physiologic justification.

I imagine that over the past few centuries, the practice has evolved from child raising “common sense” into medical folklore that has been carried forward through the years by its own cultural inertia. It also doesn’t hurt that it is an active process that likely gives parents a feeling of some degree of control in the swirling chaos of colic. Rather than screaming into the void, they have the wiggle butt to provide a bit of solace and stability.

The concept of swallowing large amounts of air during feeding is suspect, however. The esophagus, unlike the trachea, is not propped open by cartilage. It is compressed except during swallowing, when the cartilaginous epiglottis falls into place over the trachea and the esophagus is the path of least resistance. Air in the oral cavity during swallowing is more likely to escape through the nasal passages than to enter the esophagus.

A baby shouldn’t take air into their esophagus any more readily than readers of this post do when swallowing non-carbonated beverages. We all may swallow a small amount air while feeding but there is absolutely no plausible reason to blame fussiness or spitting up on this other than the desire to blame something, anything for what is largely a random process in the vast majority of infants. When an older child or adult consumes a carbonated beverage and experience a distended stomach and the need to burp, pain is rarely a complaint. And just like them, babies don’t need really help burping either.

There is nothing about an infant’s physiology that prevents them from burping on their own, even if it wouldn’t be intentional. In fact, their physiology probably makes it easier for them to burp than older children. Infants, because of a general immaturity of the nervous system and gut, are prone to what have come to be labelled as “transient lower esophageal sphincter relaxation events” where the muscular valve between the esophagus and the stomach relaxes for no good reason. This tends to happen after feeds and it is the primary reason why babies spit up as much as they do.

So babies will burp when there is gas in the stomach regardless of whether or not we pat them on the back after feeds. They almost certainly burp all the time and caregivers don’t realize it because it isn’t loud or they aren’t in the room. The common anecdotal observation that burping helps babies to get the gas out is understandable though, because it almost certainly does sometimes. But again, babies burp just fine on their own and there may also be a bit of confirmation bias at play. If a parent were to keep a strict burp log, they might find that the process is a bit more random than they thought.

But is there a downside to burping? There actually just might be one. In addition to lost caregiver sleep and potentially agitating a calm or sleeping infant, burping may actually increase the likelihood that a baby will spit up after a feed. There is grand total of one study addressing the practice of infant burping in the medical literature, and it shows that burped babies are significantly more likely to spit up and no less likely to have episodes of fussiness. It was a small study with some limitations, but it is all we have and it certainly doesn’t support the practice of burping.

Now the weeds I mentioned getting into earlier. This 2018 CNN Health article on 10 mistakes that parents make with newborns lists burping issues twice, up there with safe sleep concerns and car seat safety. One of their “mistakes” is not “pre-burping” a baby:

Most of us think about burping after the baby eats. But experts say that you should also take the time to pre-burp your baby.

I have never heard of pre-burping a baby before they feed. I don’t know any experts that recommend this. A Google search only yields similar articles on the top 10, 15, or even 20 parent mistakes. In my opinion, pre-burping is even less of a thing than burping during or after feeds. Post-burping? No.

I found this brief article claiming that failure to burp a Ugandan baby prior to putting him down to sleep caused his death. According to the autopsy, the child “suffocated because of the reflux of food that had gone to his lungs”. If true, this is terrifying and it is a very common fear parents bring up in the hospital. Imagine being a parent and being told that your baby died because you didn’t gently pat them on the back before putting them down to sleep.

But unless this child had some kind of anatomical or neurological abnormality not mentioned in the article, the likelihood of a healthy infant choking to death in their sleep is essentially zero. It just doesn’t happen and the information provided in the rest of the article does not inspire confidence in its accuracy. I can think of several more plausible potential reasons for this child’s death than failure to burp.

Finally, here is a 2007 study published in Medical Hypotheses (yes, that Medical Hypotheses) that explores the potential role of infant burping as a means of reducing the risk of SIDS. This is just pure nonsense. Just for the record, the AAP may recommend burping all babies after every feed, proving that even they aren’t impervious to acting sans evidence, but it does not include gas as a modifiable SIDS risk factor because that would be even more embarrassing than having a section on integrative medicine.

Please check out this short documentary on the invention of a revolutionary machine designed to burp babies while leaving caregiver hands free to make a sandwich or defend themselves.

  • Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.

    The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

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