Infant Reflux and Formulas with Locust Bean Gum
Oral milk (regurgitation) is quite common in babies and often goes away on its own with the growth of the baby. In some formula-fed babies with persistent complaints, physicians may recommend thickened "anti-regurgitation" (AR) formulas. One of the thickeners used in these foods is carob gum (E410), which is obtained from carob seeds.
In this article, we discuss what thickened foods are, the role of the carob gum in these foods, what international guidelines and scientific studies say, and why these products should be used with the advice and supervision of a physician.
Important Notice
This article has been prepared for general information purposes. Any change you make in your baby's diet, especially the change in formula or the addition of thickeners to the food, must be made with the recommendation and supervision of the pediatrician. It is not appropriate to add products such as carob powder, carob flour or molasses to baby food or breast milk at home. Baby foods are specially formulated products, and the carob gum mentioned in this article is a completely different ingredient from the carob powder used in the kitchen.
If there are symptoms such as gushing vomiting, green or bloody vomiting, refusal to feed, inability to gain weight, respiratory distress, extreme restlessness or weakness, a physician should be consulted immediately.
What is Regurgitation and Reflux in Babies?
Gastroesophageal reflux is the return of stomach contents into the esophagus. In infants, this condition is often seen as milk coming out of the mouth after feeding and is considered physiological in most babies; that is, it is not a sign of disease. When the symptoms of reflux are disturbing enough to affect the baby's quality of life or cause complications, "gastroesophageal reflux disease" (GERD) may be in question.
The joint guideline of the North American and European pediatric gastroenterology associations (NASPGHAN and ESPGHAN) emphasizes that non-drug approaches are prioritized in the management of reflux in infants. Dietary adjustments recommended in the guideline include formula or food thickeners, reducing the volume of feeding, or more frequent feedings (Rosen et al., 2018).
What are Thickened (AR) Foods?
Thickened formulas are infant formulas that are formulated to have a higher viscosity than standard formulas. The goal is to keep the formula in a thicker consistency in the stomach, making it harder for it to come back up into the esophagus.
In a review published in 2018, it was stated that thickened formulas reduce the frequency and severity of regurgitation, may improve symptoms associated with reflux, and increase weight gain. According to the same review, rice and corn starch, carob gum and soy polysaccharides are used as thickeners in these foods. Researchers emphasized that commercial thickened foods should be preferred to adding thickeners to standard food in terms of viscosity, digestibility and nutritional balance. According to the review, these foods; It is indicated in formula-fed infants whose complaints persist despite reassurance and appropriate feeding volume (Salvatore et al., 2018).
What Does Carob Gum Do in These Foods?
Carob gum is a galactomannan derived from the endosperm of the carob kernel and is an approved food additive in the European Union with the code E410. It forms a consistency when it comes into contact with water. According to EFSA's assessment, carob gum is practically not digested in man, is not absorbed intact and is significantly fermented by intestinal bacteria (EFSA ANS Panel, 2017).
The function of carob gum in infant formulas is to thicken the formula. A 2022 review stated that locust bean gum is the most studied thickening agent in thickened anti-regurgitation formulas, with limited side effects. However, the same review emphasized that a particular thickener cannot be recommended as superior to others due to the lack of comparative studies (Barbieur et al., 2022).
For general information about carob seeds and gum What is Carob Seed? You can check our article.
What Do the Guidelines Say?
In the joint guideline of NASPGHAN and ESPGHAN dated 2018, the main evaluations regarding thickened nutrition can be summarized as follows (Rosen et al., 2018):
- The study group recommends the use of thickened feeding in the treatment of visible regurgitation and vomiting in infants with GERD.
- Darkening reduces visible regurgitation; however, its effect on symptoms other than regurgitation is less clear.
- It is reported that thickening does not improve acid reflux parameters assessed by pH measurement.
- There is no conclusive data to show that one thickener is more effective than another.
- The guideline states that carob-based thickeners are approved for use in infants after 42 weeks of gestational age.
This last point is particularly important: the use of thickeners in preterm (premature) babies requires a separate evaluation and can only be carried out by the decision of a specialist physician.
Findings from Scientific Studies
There are several studies conducted with foods containing carob gum:
Real life study (France, 2020). In a month-long open-label observational study including 2,604 infants with an average age of 9.3 weeks, the frequency and estimated volume of regurgitation decreased significantly in infants using formula thickened with carob gum, and regurgitation was completely eliminated in 48 percent of infants. Stool frequency increased and its consistency softened, but the values remained within the physiological range. The study was funded by a formula manufacturer (Tounian et al., 2020).
Randomized controlled trial (multicenter, 2024). In 103 infants with regurgitation, formula containing 0.4 grams of carob gum per 100 mL was compared with unthickened control formula. At the end of eight weeks, the test group's stool was not found to be more watery than the control group, and the frequency of regurgitation was significantly lower in the test group (Salvatore et al., 2024).
A study from Turkey (2026). In the study, in which 26 premature infants followed up in the neonatal intensive care unit at Selçuk University were retrospectively examined, a short-term improvement was observed in digestive tolerance indicators such as stool consistency, straining, abdominal distension, and flatulence on the seventh day after starting anti-regurgitation formula containing carob gum. The researchers stated that the findings should be confirmed by prospective studies of sufficient strength (Konak et al., 2026). It should be underlined that this study was conducted under intensive care conditions and under the supervision of a specialist physician.
It should be taken into account that a significant part of these studies are supported by food manufacturers and some of them are carried out without a control group.
EFSA's Security Assessment
The European Food Safety Authority (EFSA) evaluated the carob gum in two stages.
2017 review. EFSA concluded that there is no need to establish a numerical acceptable daily intake for carob gum and that there are no safety concerns in the reported uses for the general population. However, it has stated that infants and young children fed foods for special medical purposes may be more susceptible to the effects of carob gum on the digestive system due to their underlying medical conditions, and the available data do not allow for an adequate assessment for this group (EFSA ANS Panel, 2017).
2023 review. EFSA re-evaluated the use of carob gum in foods intended for infants under 16 weeks of age and in foods for special medical purposes. The panel set a reference point of 1,400 mg per kilogram of body weight per day based on reduced blood zinc levels in a study in piglets and used a safety margin approach. The assessment reported that the safety margin was above 1 in some scenarios and exposure levels for infants, and above 1 at all exposure levels for young children who consumed only food for special medical purposes (EFSA FAF Panel, 2023).
These evaluations show the importance of using the carob gum in infant foods at controlled and determined levels. Usage levels in commercial foods are determined by legislation; this control is not possible for additions to be made at home.
Risks of Adding Thickener at Home
In some countries, locust bean gum-based thickeners are sold for addition to breast milk or standard food. In a laboratory study conducted in Belgium, it was shown that by adding such thickeners to the food, the viscosity increased exponentially from 25 percent of the recommended dose. In other words, small changes in dose can drastically change the consistency of the food. In the same study, it was reported that the carob gum reached its final consistency only after about 30 minutes; the researchers emphasized the importance of educating parents about proper preparation and waiting time (Baert et al., 2024).
These findings explain why commercial thickened formulas are preferred over the addition of thickeners later (Salvatore et al., 2018) and why all types of thickening applications should be done with the recommendation of a physician. A formula that is too thick may cause the baby to expend more energy during sucking and cause feeding difficulties.
In addition, although rare, hypersensitivity reactions to carob gum have been reported; for example, a case of food protein-induced enterocolitis syndrome (FPIES) triggered by carob gum in an infant has been published (Jędrzejczyk et al., 2020).
Frequently Asked Questions
Do carob gum foods treat reflux? According to the guidelines, thickened foods can reduce visible regurgitation and vomiting; however, it is reported that they do not improve acid reflux parameters. These foods are a recommended dietary arrangement after a physician's evaluation.
Can I add carob powder to food at home? Carob powder used in the kitchen is a different product from the carob gum used in formula. No product should be added to baby food or breast milk without the recommendation of a physician.
Can carob gum foods be used in premature babies? The guideline states that carob-based thickeners are approved for use after 42 weeks of gestational age. Any nutritional decisions in premature babies should be made by a specialist physician.
Is carob gum safe? EFSA stated that there were no safety concerns in the reported uses for the general population. Use in infant foods was further evaluated and attributed to specific conditions.
A Note on Carob Seeds with Carob Türkiye
The use of carob gum in baby food is one of the examples that shows how valuable and technical carob seeds are. However, baby foods are special products subject to strict legislation and this article is not a product recommendation.
At Carob Türkiye, we supply carob fruit, crumbs, flour/powder, kernels, and extracts. For information about carob seeds Carob Seed You can review our page, for your wholesale and export requests You can contact us.
This content is for informational purposes only; it is not a substitute for medical advice.
Domestic resources
Konak, M., Kılıçlı, E., Uygun, S.S., Namal, H., "Short-Term Gastrointestinal Tolerance and Oxygenation Changes After a Locust Bean Gum-Containing Formula in Preterm Infants: A Retrospective Paired Cohort Study", Nutrients, 18(11), 1834, 2026 (Study conducted in Turkey). doi.
org/ 10. 3390/ nu18111834 Foreign sources
Rosen, R., Vandenplas, Y., Singendonk, M., Cabana, M. et al., "Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition", Journal of Pediatric Gastroenterology and Nutrition, 66(3), 516–554, 2018. doi.
org/ 10. 1097/ MPG. 0000000000001889 Salvatore, S., Savino, F., Singendonk, M., Tabbers, M., Benninga, M.A., Staiano, A., Vandenplas, Y., "Thickened infant formula: What to know", Nutrition, 49, 51–56, 2018. doi.
org/ 10. 1016/ j. nut. 2017. 10. 010 Barbieur, J., Levy, E.I., Vandenplas, Y., "Efficacy and safety of medical and nutritional management of gastroesophageal reflux in formula-fed infants: a narrative review", Current Opinion in Pediatrics, 34(5), 503–509, 2022. doi.
org/ 10. 1097/ MOP. 0000000000001147 EFSA Panel on Food Additives and Nutrient Sources added to Food (ANS), Mortensen, A. et al., "Re-evaluation of locust bean gum (E 410) as a food additive", EFSA Journal, 15(1), e04646, 2017. doi.
org/ 10. 2903/ j. efsa. 2017. 4646 EFSA Panel on Food Additives and Flavourings (FAF), Younes, M. et al., "Re-evaluation of locust bean gum (E 410) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation as a food additive for uses in foods for all population groups", EFSA Journal, 21(2), e07775, 2023. doi.
org/ 10. 2903/ j. efsa. 2023. 7775 Tounian, P., Meunier, L., Speijers, G., Oozeer, R., Vandenplas, Y., "Effectiveness and Tolerance of a Locust Bean Gum-Thickened Formula: A Real-Life Study", Pediatric Gastroenterology, Hepatology & Nutrition, 23(6), 511–520, 2020. doi.
org/ 10. 5223/ pghn. 2020. 23. 6. 511 Salvatore, S., Klymenko, V., Karpushenko, Y., Durczak-Hilleman, M. et al., "Tolerance and Safety of an Anti-Regurgitation Formula Containing Locust Bean Gum, Pre-, and Postbiotics: A Multi-Country Multi-Center Prospective Randomized Controlled Study in Infants with Regurgitation", Nutrients, 16(6), 899, 2024. doi.
org/ 10. 3390/ nu16060899 Baert, K., Ombecq, M., Van Winckel, M., Henry, S., Tommelein, E., Vanhoorne, V., "The viscosity-enhancing effect of carob bean gum and sodium carboxymethylcellulose when added to infant formula", Food Science & Nutrition, 12(4), 2661–2670, 2024. doi.
org/ 10. 1002/ FSN3. 3947 Jędrzejczyk, M., Bartnik, K., Funkowicz, M., Toporowska-Kowalska, E., "FPIES Induced by Locust Bean Gum in an Infant", Journal of Investigational Allergology and Clinical Immunology, 30(3), 197–199, 2020. doi.
Scientific Resourcesorg/ 10. 18176/ jiaci. 0475
