Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

Reflux - broken babies or profitable product?

As those who know me will testify, the subject of infant reflux (or gastrointestinal oesophageal reflux GOR)  is one that launches me on to my soapbox at a rate Dick Fosbury would have been impressed with.  So I thought a blog piece might save me repeating myself quite so often...

Reflux has to be one of the most over diagnosed and yet least understood conditions of the 21st Century.  Ask anyone above about forty and they look puzzled when you toss the term about - yet seemingly every other baby at a group now suffers from this rapidly spreading problem.  It seems to have replaced "colic" at the doctors surgery - new mother, baby crying a lot, back arching; ah that will be reflux.  Gaviscon prescription please!  I would love to know just how much Gaviscon's profits have increased since this new trend.

On the flip side, infants with moderate to severe reflux (which can cause serious issues from aspiration to oesophageal damage) seem to really struggle to get anyone to take their problem seriously, beyond Gaviscon!

What is infant reflux?
As those listening at Chemistry class might remember, the term "reflux"  (from medieval Latin reflūxus) means "flowing back".  So, when you tell your doctor your baby is frequently being sick (sometimes copious amounts) and he tells you the baby has "reflux"; he is simply repeating back to you what you told him, using a more impressive sounding word. 

If he adds "gastrointestinal oesophageal" he is telling you what is refluxing and where, ie contents from the stomach, into the oesophagus.  If the amount of sick isn't sufficient to be termed reflux - it's considered normal "posetting".  Generally reflux is forceful vomitting, whereas posetting is the effortless mouthful of milk infants can bring up after a feed (which can still look an impressive amount at the time, but isn't comparable to projectile).

If baby isn't vomiting, but is very unsettled for long periods (read as screaming!),  arching their back and displaying unusual feeding behaviour such as fussing, refusing or feeding very frequently - this is termed "silent reflux".

At the most extreme end of the scale the condition is termed GORD (gastrointestinal oesophageal reflux disease or Pathogenic GOR).  Babies with GORD suffer from excessive reflux which if not appropriately managed leads to complicationd such as; inadequate growth, failure to thrive, feeding aversions and oesophagitis, or atypical complications such as wheezing, pneumonia and chronic sinusitis.  It is more common in children with neurological impairments or physical abnormalities, and it is estimated around 3 in 1000 infants display symptoms of GORD.

Those who reflux without weight gain issues or apparent distress are labelled "happy spitters" and these babies are generally not medicated.


The vast majority of typical infants will outgrow reflux by around their first birthday - even those who suffer severely when younger.

So what's my problem?
A reason that is often given for around 60% of infants suffering from reflux, is that they have a weaker lower oesophageal sphincter (the muscular ring at the lower end of the oesophagus), making them more prone to refluxing stomach contents - but given the number now diagnosed with this condition, why are babies suddenly suffering en-mass from abnormally weak stomachs?   I don't doubt there are some with an unusually weak valve, or other physical condition, but I do believe these are the minority.

Infants suffering with moderate to severe reflux can be naturally very distressed, there can be risk of aspiration as discussed and it can be a worrying and exhausting time for parents.  Isn't just handing out mediction without investigation unfair?

Why?
Because several things are known to cause reflux - yet instead of looking at possible reasons why a baby is refluxing, the doctor (with little breastfeeding training or experience and likely pushed for time), deals with trying to stop the symptoms via medication.

Causes

Tongue Tie/High Palate - This in my experience almost always causes either reflux, wind or both.  If you had problems feeding previous infants, have experienced nipple pain during your feeding experience (even if this has now ceased) have a baby that is fussy/unsettled/hates being put down/hates the carseat/feeds for a long period or feeds very frequently - rule this out before you start cutting things you love from your diet!  Removing dairy in my opinion can potentially cause a reduction in symptoms - even if it's not the cause )more about dairy further down)... The tongue co-ordinates sucking/swallowing and breathing meaning any variation can cause further problems. (Brian Palmer also has also linked a restricted frenulum to acid reflux).  Baby may present just as an oversupply baby, ie milk running out of sides of mouth, loud audible gulping, spluttering.  Secondly baby needs to maintain a seal to form a vacuum when feeding, extremely difficult if you're tongue is restricted - causing increased intake of air again and difficulty obtaining fatty milk.  I'm halfway through a blog entry specifically focusing on this!

Gut Flora - Candida (thrush), antibiotics and various other triggers such as food intolerances are linked with a less healthy gut flora.  Probiotic supplement has been found by some sources to reduce colic/reflux symptoms.

Milk over supply/fast letdown - Reflux caused by a large supply or fast letdown is typically mild to moderate, and will in my experience usually manifest itself from around 3 weeks onwards, with 6 weeks being a prime time.  Mums often comment baby gulps, coughs, gasps, splutters, clamps down, pulls from the breast or guzzles.  Some find baby will feed until letdown - then pull off, arching and fussing or if it's severe refuse to latch at all.  Other babies just appear to be fast feeders and don't seem to suffer until later.  If mums have a large over supply, baby may display symptoms similar to that of a secondary lactose intolerance, as the infant struggles to produce enough lactase to digest all the lactose rich milk.  See foremilk/hindmilk and a lot of confusion, for further information about this.  If you think this may be the case, contact your local Lactation Consultant or registered Breastfeeding Counsellor who can discuss this further with you.

Latch/attachment problems - If baby is not well attached he is unable to milk the breast effectively.  This may prevent him from effectively releasing the fat and result in more lactose rich milk (along with perhaps several other issues).  Supply may decrease longterm with incorrect attachment, therefore if you think this may be the case contact your local Lactation Consultant or registered Breastfeeding Counsellor who can discuss this further with you.

Long feed spacings - Whereas in many countries, babies are fed little and often (the optimum way for a human infant) Western feed spacings are quite different.  Typically larger volumes or milk are transferred less frequently, because this fits with what women expect (based on a non breastfeeding culture).  Whilst some infants adjust to this pattern, others struggle with this unexpected strain on their gut.  The reason this problem may be increasing is also due to mum's diet becoming more calorific, which in turn may lead to larger volumes of milk per sitting.  Combine with a larger gap and letdown can easily become overpowering - hitting the stomach before refluxing straight back up!

In addition mums in the West are more like to do things we know contribute to the incidence of reflux; such as feed in positions which place baby laying down on their back fighting gravity, and then again in the cot, pram or moses basket after a feed.  Compared to other cultures, Western infants spend a lot of time on their backs (hence the increasing rates of Plagiocephaly/Flat Head Syndrome, but that's one for another post!).

Residual Birth Trauma - Long births, C-Sections, extremely fast births, posterior pregnancies and labours can all impact. Baby takes immense forces through the sacrum and occipital area (back of head) during labour, which can compress the nerves linked with digestion.  Furthermore if the diaphragm becomes distorted, it can compromise the ability of the gut to retain it's contents (ala reflux).  Some mums note amazing results with Cranio-Sacral Osteopathy - Annalisa Barbieri wrote an article about birth and osteopathy when her daughter was diagnosed with reflux.  A basic introduction well worth a read if the above describes your labour is this

Cow's Milk Protein Allergy - Unfortunately many paediatricians are still telling mothers if their baby doesn't have IgE mediated allergy (the typical hives, swelling etc) - it's not the cow's milk protein; absolutely not true.   There are at least 30 antigenic primary proteins in milk, which can get through the digestive tract intact and cause reflux.  These antigens can also be responsible for delayed immune responses, producing disease in any and all tissues.
 
Interestingly untreated allergy can lead to a litany of gastrointestinal, respiratory and/or dermatological problems; with increased rates of infection, particularly in the ears and sinuses.  This can result in pain, recurrent illness, poor growth, delayed development and failure to thrive.”  Now read back up to the symptoms of GORD and compare the two - how many cases of allergy are misdiagnosed and mismanaged as severe reflux?  Dairy can also hide in foods you would never expect, under various guises.  Many infants allergic to dairy also display a similar reaction to Soy products.  If you suspect milk protein may be an issue, look for information about "non IgE mediated allergy" and contact your location Lactation Consultant or Breastfeeding Counsellor and your Doctor.
 

Prematurity - Premature infants are more likely to reflux feeds than a term baby due to immature development and reduced muscle tone.  Again our culture gives much larger feeds, more infrequently than experts suggest biologically normal.

Will stopping breastfeeding help?
No.  Reflux is FAR more common in the non breastfed infant  Those fed by bottle typically have longer feed spacings, increased volume and increased exposure to cow's milk protein.  As discussed in this blog post, it's also a lot easier for bottle feeding mums to overfeed their baby causing reflux.  For the majority of mothers, introducing bottles full-time, also results in formula usage.  The impact of this on the health of the infant must therefore also be considered - the bacteria profiles of a breastfed and one receiving a breastmilk substitute are very different, some sources list overgrowth of bad bacteria as a reason in itself for reflux.  If this is suspected, pro and prebiotic supplementation may help the non breastfed baby.

If allergy to cow's milk protein is suspected, eliminating from mum's diet (in all forms mentioned above) prevents baby receiving any!

Updated 2011

25 comments:

  1. Agree totally - our experiences with gaviscon were just awful.... I gave up dairy for 6 months and it helped a lot. I did not find the medics (in my part of the world anyway) even seemed to understand about silent reflux. For us it was certainly not a question of being-over disagnosed. It was a long hard battle and I very nearly gave up breastfeeding because my daughter went completely on strike several times and only really fed at night. I thought my daughter hated breastfeeding because she didn't react the same way to a bottle of ebm :( I later came to understand that it was only because she hadn't yet made an association between a feeding bottle and her pain. We stopped giving her ebm in a bottle at that point. Our doctors were useless and we only found the RIGHT medication through a chance encounter with a very pro-bf out of hours doc. It really did change our lives.
    Great article, but I am of the belief that silent reflux is often mis-diagnosed or not diagnosed at all - particularly when the baby comfort-sucks and has no weight gain problems. Both types of silent reflux can be really hard for a mum to deal with without good support - but it CAN be done, so keep shouting until you get the right help!

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  2. Hiya
    Yes the dairy allergy link is a fascinating one. It's also interesting how some mums seem to only need to cut "raw dairy" such as milk to notice an improvement, whilst others need to cut cheese/yoghurts, dairy in all it's hidden forms and some even all bovine protein!

    I wonder if silent diagnosis is again one of those things that varies area to area? We had "reflux" with number one (and gaviscon) which was diagnosed as "silent reflux" as she was never sick. I later realised it was several breastfeeding issues that hadn't caused me enough problems to be flagged at the time...

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  3. I suspect, as in many things, northern Ireland is 15 years behind the 'mainland' in terms of gp's! I did ask for, and get, a referral to a dietician which was v helpful. I was told any milk proteins at all had to go- but I realise others may know more. Thing is- how do you tell unless you remove all dairy, and then 'trial' reintroductions? Not worth the risk for us.

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  4. Interesting post! It does seem that every baby is now a "reflux baby" and medication is always the first suggestion. Do we even know the long term effects of babies consuming such harsh antacids? Probably not. In my circle of friends, I have definitely noticed the babies who were induced or sectioned without a TOL seem to also have the babies with the worst reflux. There is definitely something to be said for birthing your baby peacefully and when baby signals they are ready. My homebirthed babe never threw up at all!

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    1. HI Brittany, great observation and scientifically correct. There is a correlation between cesarian births and a greater chance of developing GORD (Silent Reflux).

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    2. Now we are finding out that gut bacteria has the most to play in that regard... and would state the same for GORD and other GI issues in babies...
      Given CSections usually bypass the advantageous bacterial introduction, the gut bacteria is different and hence this may start all sorts of issues...

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  5. QUOTE Even where mum does not have an allergy to dairy etc proteins cross the permeable gut membrane before 6 months of age

    But if mum doesn't hae a leaky gut, the dairy/wheat proteins wouldn't be in breastmilk in the first place?

    I'm not sure what you mean by keep referring to GORD. I mention it at the top:
    QUOTE Babies with GORD suffer from excessive reflux which if not appropriately managed leads to complicationd such as; inadequate growth, failure to thrive, feeding aversions and oesophagitis, or atypical complications such as wheezing, pneumonia and chronic sinusitis. It is more common in children with neurological impairments or physical abnormalities, and it is estimated around 3 in 1000 infants display symptoms of GORD. END

    My experience is those with severe dairy allergy can experience all the above - including those treated with strong reflux meds without investigation, who have not improved until dairy was removed. Though of course it can also occur for other reasons mentioned.

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  6. LOL - Just re-read this, and you have reminded me about repeated sessions at a cranial osteopath an hour. Funny how you forget things so quickly... :-S Although I think cranial osteopathy probably does work in some cases of reflux due to birth trauma -(and the traumatic birth thing certainly applied to me dd)- I'm sorry to say the results for us weren't noticeable.

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  7. * sorry - should read, an hour away from our house! Sorry for typos - ifungers!

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  8. Wow, I wish I had this to read a year ago. 4 months of screaming and 2 nursing strikes later I stopped eating dairy and within 24 hours she was a completely different baby. Not looked back since and I still have a happy breastfeeder 14 months on. I wish the medical profession were more informed about these things, it would've saved us a lot of heartache. I can't help but feel a little robbed of enjoying my new born little girl, I only really met her when I cut out dairy. The re-introducing is going really well, you would never know she had it now.

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  9. 1stborn (now nearly 5) was a tense, back-arching, bad-latching, every 2hr for 90 minutes kind of feeder. No vomit. No-one suggested reflux. Quite glad they didn't tbh, having tried to get infacol into her once I'm pretty sure trying to do that with Gaviscon before every feed would have led to the end of our breastfeeding relationship (which despite massive issues continued for 4yrs in the end), and we found our own way through - lots of long feeds and lots of slinging. We also tried osteopathy in desperation (I actually don't believe it does anything beyond placebo - no evidence - though placebo is very powerful of course) because when your babe seems to be in distress you feel like you have to be *doing* something. Can't help thinking that if we were all allowed to just let us and our babies *be* whatever they are, without thinking we have to fix it, we might be able to relax into parenting our newborns a bit more. That's not, of course, suggesting we should ignore genuine medical need!

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  10. Hi Hilary
    Was tongue tied ruled out in your case? I think there may be different results depending upon whether you see a paediatric specialist trained osteo - all I can tell you is evidence or not (I've never searched) I've personally witnessed amazing results. Only a few weeks ago was a baby who had no protrusion which after one session was protruding fantastically. I have witnessed osteos that don't have great results, including one I saw myself. I personally only deal with one particular person who is a UK leading paediatric specialist.
    I think some cases absolutely you can let baby be "who they are" (unless this is significantly changed by something no?) but tell that to a mum who either has an infant feeding 14 hours per day or who wont feed apart from tiny short powerfeeds!

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  11. Regarding bovine proteins - I had to cut out most dairy for a few months with my daughter. What I failed to check was the list of ingredients in the jabs. Wouldn't you know that there are bovine proteins in some of the jabs?! I think it was the DTaP, and can't remember if it was the MenC or PCV. My daughter, of course, reacted the same way to those as she did if I'd eaten dairy. :-(

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  12. Fairly sure not tongue-tied, unless very slight, as she could stick her tongue out to copy when I did it. Hadn't heard of high palete though... And I spent a *lot* of time with BFCs (had wrecked nips for 10weeks or so) did peer support training later so reasonably well-informed on looking for probs, but always possible we all missed something of course. And yes I *totally* get the desperation of the mum with a permanent feeder/evening screamer/whatever because I was desperate too, and of course some kids absolutely need medical intervention, dietary change etc etc. Not suggesting folk shouldn't try it/take advice as they want & need. Just wondering if part of the rise of diagnosis of a whole range of things isn't due the medicalisation/problematising (is that a word?) of a bigger and bigger range of infant behaviour that our grandparents' generation would consider normal? And babies change so quickly during the newborn phase it's very hard to know if a particular intervention has made a difference or if they'd have settled down/changed behaviour that week anyway. Newborn phase was one of the most bewildering times in my life with my firstborn.

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  13. And if you have reflux - what makes it worse? Lying down. It almost seems as if big business sells us everything to stop us picking up and cuddling our babies - there's a good reason our Grandmothers take babies off us and pop them upright over their shoulders for a good burp and a cuddle after we have fed them.

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  14. I am a mom of premies, what would you have had me do, allow my child to starve until they "outgrew" the reflux? They didn't pass this phase until they were over 2 and that is with using soy based formula and gaviscon. Some times medication is necessary and not all parents are looking for quick fixes.

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  15. My little one had awful reflux - we did everything - he was always in a sling, tried to alter feeds (though he had a great latch from the first feed not long after birth)... he was always screaming and hardly slept, had a big bloated tummy and his poos were like green jelly... ended up being severe allergies to lots of things - I continued to breastfeed him but I was on a diet of chicken, rice, potato, pears celery for over 6 months etc which helped, ... it was awful at the time but as his tummy matured he was able to tolerate more and more variety of food (did baby led solids using low allergy foods) and now at 2 years old can eat most things except dairy and artificial colours, flavours etc I am still breastfeeding but eating dairy myself now and he is tolerating that now too. Despite figuring out the link to diet early on (about 2-3 months old) he was still in pain so we had him on Losec medication till he was 12 months old... I couldn't bear seeing him in pain... we tried several times to go without the Losec but he honestly did need it.

    Anyway, wasn't a fun time, but now we are on the other side I think it did strengthen our relationship - because of the reflux I learnt all about slings & co-sleeping, and we were there to comfort him every time he was in pain so he learnt to trust us in a really deep way... thought if we have baby no 2 I think I will start on an elimination diet right from the start just in case :))

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  16. Do you delete all constructive comments you disagree with? This page is really unhelpful and misguided. Things have moved on a LOT in the reflux/allergy world and you should really update yourself ;)

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  17. I haven't deleted any comments Twin plus Two?

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  18. Interesting article. My daughter had reflux and was on *all* meds, not just nonmedicinal gaviscon (omeprazole, ranitidine and domperidone). She was started on these in picu. I trust that she needed them.

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  19. in a bottlefed baby who is projectile vomiting with all of the wonderful reflux symptoms diagnosed gord, could tongue tie still be an issue?

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  20. Some things I agree with, like drs aren't up with the play mostly, just drug pushers. I had a screamy, nightmare baby and I was told that babies cry and I'm obviously not coping. Until about 4 months I put up with the constant screaming until my mother in law took us to Cranio-Sacral and we had four visits with mild success. I had been giving him probiotics because of the antibiotics (I'm sure the antibiotics didn't help but still being alive made it totally worth it) at birth and I cut all dairy out for a few weeks and he always slept on me upright because he hated lying down, which I told my midwife about and she just wrote it in the book so I didn't think twice, if she didn't worry then neither would I. Then he stopped feeding for a few days so I called a help line and he ticked all the boxes for silent reflux. Well, I thought a refluxy baby was supposed to be spilly so it never crossed my mind! I went to the dr, she didn't want to give him the drugs as much as I didn't but I was desperate and she didn't believe it was reflux so I begged for it. Well, I gave him 1ml as soon as I got home and he slept for 4 hours and for as long as I gave it to him until it went away when he started sitting, he had no more symptoms. We had our lives back and I could start to enjoy him and he started to enjoy life. So yes, it is awful to give a little baby medication but is awful to think he could have spent 6 months solidly crying and only sleeping when he couldn't cry anymore. He was still grizzly but he had had such a hard start and whatnot but with the right comforting and reassuring he came right at 11 months and now he is such a joy with no problems what so ever. So I think your article is a bit simplistic, black and white. I do not regret giving him the medicine but I do feel bad about having to. In this case I feel that the benefit outweighed the risk. Watching all the other mums play with their babies and the nurses coming around to my house to show me dvds about how to care for baby and play with him made me feel so shit because all we could do is walk up and down the hallway in a front pack for hours just to try get him to sleep or at least stop crying. I couldn't even eat chocolate to relax. Awful, awful times. Basically, you're making people feel bad about resorting to meds and or formula (only if you don't have any choice) when in reality it isn't a long period of time but when you have a screaming baby it feels like an eternity. Long post I know but I just want to make it clear to anyone who is struggling that meds are actually an option! We used ranitidine rather than omeprazole or gaviscon. It has been around longer so more is known about it in regards to babies and omeprazole isn't recommended on babies under one as the side effects can be worse. Phew, what a rant!

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  21. I've been shot down in flames on one of the reflux forums for suggesting bottle fed babies can be overfed. But, I am very curious if there's a link between 'feeding on demand' and the increase in acid reflux in babies.The symptons for overfeeding are practically the same as reflux and if a mother is giving a child a bottle everytime it cries then it's not impossible to imagine that child overeating. According to a paediatric nurse friend on mine, there's also a big increase in overweight babies. Be interested to hear what you think.

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