Reflux


Reflux

Reflux is so frequently blamed for unsettled behavior displayed by babies that its now one of the first things a parents worry about when their baby cries for reasons that are not obvious, or appears to have trouble falling asleep or staying asleep, or fusses during feeds or refuses feeds. In most cases reflux is neither cause for concern or responsible for the baby’s troubled behavior.

To appreciate why babies reflux, and the rare circumstances in which this can cause problems, begins with an understanding of the difference between what’s normal and what’s not when it comes to gastro-esophageal reflux. 


What is reflux?

Gastro-esophageal reflux refers to the backwards flow of stomach contents into the esophagus (food pipe). It might continue into throat, mouth or out of the mouth.

Spitting up, posseting, spilling, throwing up, chucking up, vomiting, regurgitation, and rumination are some of the many words used in reference to gastro-esophageal reflux.

Other terms include; gastric reflux, acid reflux, silent reflux, GER (gastro-esophageal reflux), GERD (gastro-esophageal reflux disease) and heartburn.


Is reflux problematic?

Reflux can be classified under two different categories:

1.     GER (gastro-esophageal reflux) due to physiological reasons, i.e. normal bodily functions. 

2.     GERD (gastro-esophageal reflux disease), due to pathological reasons, i.e. abnormal bodily functions, illness or disease. 

What is often confusing for parents is that some people use the term GER when they are referring to GERD. To identify which category your baby’s reflux falls into, first consider normal physiologic GER and then compare this with pathologic GERD.


GER - physiologic reflux

For the vast majority of healthy, thriving babies spitting up is not a condition that requires treatment, rather it is a phenomenon (a natural happening) that requires understanding.

Studies show that 50 percent of healthy babies from birth to 3 months, 67 percent of babies aged 4-6 months, and 5-10 percent of babies at 1 year will spit up one or more times each day.[i] 100 percent of healthy babies regurgitate milk into their oesophagus, throat or mouth periodically without spitting up. This is referred to as 'silent reflux'. This can occur numerous times each hour and still be considered normal.



[i] Nelson SP, Chen EH, Syniar GM, Christoffel KK. Pediatric Practice Research Group. Prevalence of symptoms of gastroesophageal reflux during childhood. Arch Pediatr Adolesc Med. 2000; 154: 150-154.


Cause

All of us, big and small, regurgitate stomach contents from time to time. As adults, we don’t tend to spit up, but babies often do. The following are reasons why babies are naturally inclined to spit up.

  1. Between the esophagus and stomach there is a ring of muscle fibers called the lower esophageal sphincter, or LES. This opens to let food in and closes to prevent the backward flow of stomach contents. In babies the LES is immature and does not always close well.
  2. Babies consume large volumes of milk in proportion to their body size. In relation to size, this would be like you drinking ½ to ¾ of a gallon (2-3 litres) of milk in one sitting.
  3. As a liquid, milk is easily refluxed up, particularly with a burp.
  4. Any pressure on a baby’s full stomach as a result of lying over a parent’s shoulder, sitting in a slumped position, or lifting baby’s legs to change a diaper, can cause regurgitation of stomach contents.
  5. Babies have a strong sucking reflex until around the age of 3-4 months. This means newborn babies can easily overfeed if parents aren’t careful. (See Hungry baby for more on overfeeding.)
  6. Feeding too quickly increases the risk that a baby will overfeed. It also increases the amount of air swallowed.
  7. Excessively large volume feeds and/or large amounts of swallowed air owing to overfeeding can hyperextend the stomach. Stretch receptors in the stomach wall trigger contractions that then force stomach contents backwards up into the esophagus. It is believed that GER is a natural body defense mechanism that acts to protect against overfeeding and/or overeating.
  8. Babies in general spend a lot of time lying down. This makes it easier for the backwards flow of milk from the stomach.


Signs of physiologic reflux

* Spitting up can vary from tiny milk dribble to large projectile vomit that shoots out of baby’s mouth with such force that it lands many feet away.

* Spitting up can be frequent or occasional.

* Milk might come out of baby's nose.

* Baby calms quickly after spitting up. (She might get a fright when it comes up with force.)

* Baby gains weight well.  

In the case of GER, regurgitation of stomach contents is not painful for a baby. However, the baby could be irritable, wakeful or fuss during feeds due to other reasons; for example, gastro-intestinal discomfort owing to overfeeding; hunger due to underfeeding; distress due to sleep deprivation and/or overstimulation; or feeding refusal owing to a behavioral feeding aversion


Why GER does not cause pain

Whether regurgitated stomach contents are acidic or not depend on many variables, such as the type of food consumed and the time stomach contents are regurgitate in relation to the feed. Even when regurgitation occurs when stomach contents are acidic, this does not automatically cause harm. The human body has numerous protective mechanisms that act to maintain a state of harmony within the body.

Neurologically, normal, healthy babies under the age of 4 months of age don’t produce sufficient quantities of stomach acid to cause burning of the esophagus. The reason is because babies are biologically designed to drink human milk. Breast milk contains easily digestible proteins and digestive enzymes; therefore a healthy newborn does not need to produce large quantities of stomach acid until they reach the age when they are ready to start eating solid foods.  Even when a baby is fed infant formula, this does not change her inborn biologically programming. A newborn formula fed baby is more likely to experience abdominal discomfort owing to trouble digesting the amount and type of protein in infant formula than be troubled by acid reflux.

Breast milk and infant formula have a neutral acid balance. When a baby brings up milk, this is unlikely to burn her oesophagus.

Regurgitation of stomach content is more likely to occur when the stomach is full (a time when the pH of the yet to be digested milk is unlikely to be at a level where it will burn) or when there is pressure on the stomach. The time when stomach contents are most likely to be acidic is a time when regurgitation of stomach contents is least likely to occur.

The esophagus has a muscular wall which contracts and pushes food and fluid towards the stomach. Any refluxed stomach contents will be pushed back into the stomach within a matter of seconds. The wall of the esophagus has a mucosal lining that protects the underlying tissues against brief episodes of acid reflux. In most cases, when babies refluxes acidic stomach contents, the worse they experiences is a bad taste in their mouth.


How long does GER last?

Adults experience GER from time to time, usually after overeating. Mostly this goes unnoticed. They only recognize they have refluxed if it reaches their mouth. So babies never outgrow reflux. However, babies tend to spit up less as they mature.

A decline in the incidence of spitting up can be seen once a baby starts eating solid foods, around 4-6 months, and also when she spends more time in seated position, usually around the age of 6 or 7 months. Spitting up can increase in frequency when the baby starts creeping (crawling) at around 9 months of age, owing to spending more time in horizontal position once again. Once a child starts walking, around 12-18 months of age, spitting up often no longer occurs.


Myths about reflux

1. Acid reflux is a common cause of infant distress.

FALSE: 'Acid reflux' is commonly blamed for infant distress, but it’s rarely the cause. Acid reflux is a common problem for adults, but not babies. Adults are at risk of acid reflux owing to lifestyle factors including being overweight or obese, overeating, eating or drinking fatty or acidic foods, smoking and pregnancy. Only a tiny percentage of babies are at risk of suffering complications owing to acid reflux, and in these cases its is usually due to an underlying physical problem (described further below). 

2. Back arching is a sign of reflux.

FALSE: Around 1 percent of babies suffering pain as a result of esophagitis (inflammation or ulceration of the esophagus) due to acid reflux display a particular behavior called Sandifer’s Syndrome. This is very different to back arching. Normal healthy babies back arch for a number of reasons. Babies younger than 3 months have poor head control. If a newborn’s head flops back this can trigger the tonic labyrinth reflex, which in turn causes the baby to arch back. This reflex disappears around 3 months of age. Older babies will back arch owing to frustration or to distance themselves from the source of their distress. For example, a baby troubled by a behavioral feeding aversion might back arch to distance himself from the breast or bottle if the parent ignores his cues that indicate he wants to stop feeding, and instead the parent persists in trying to make him feed.

3. Babies troubled by acid reflux demand frequent feedings in order to soothe their throat.

FALSE: Untreated acid reflux causes inflammation or ulceration of the esophagus. This makes it very painful for a baby to swallow. A baby with untreated acid reflux will try to avoid feeding because they will learn that its painful when they feed. Her growth will be poor owing to her aversive feeding behavior. If a baby appears to want to feed more often than expected, there are usually other reasons involved. (See Hungry baby.) 

4. If a baby is not a ‘happy spitter’ (or ‘happy chucker’) she requires treatment.

NOT NECESSARILY: The fact that a baby is irritable, wakeful or refusing feeds and also happens to spit up, or not spit up in the case of silent reflux, does not automatically mean the baby’s troubled behavior is due to acid reflux.

5. Hiccups are a sign of acid reflux

FALSE: Newborns in particular hiccup often. It has nothing to do with acid reflux.  


What's helpful and what's not?

As a normal physiological body action GER does not require medical treatment. However, there are generally steps parents can take to minimize spitting up. 

What’s helpful?

* Check that baby is not overfeeding.

* Feed baby in a semi-upright position.

* Ensure baby is not feeding too quickly. (See How long to feed a bottle-fed baby).

* Change baby’s diaper before feeding rather than after. If you need to change her when her tummy is full, roll her from side to side to place the diaper and clean her rather than lift her legs.

* Avoid pressure on baby’s full stomach.

* Burp baby frequently during feeding.

* Ensure baby gets plenty of sleep. Not only can this significantly reduce a baby’s irritability, it can also help to minimize the risk of overfeeding. This is because a baby’s sleeping patterns will influence her feeding patterns. If you are finding it a struggle to get your baby to fall asleep or stay asleep, in my infant sleep book entitled 'Your Sleepless Baby' I have described the ways in which parents can effectively support their baby to get the amount of sleep her little body needs. 

What’s not helpful?

A misdiagnosis of GERD (pathological reflux) is not helpful.

Based on the mistaken assumption that the baby’s troubled behavior is due to acid reflux, many parents are advised to medicate their baby and/or employ additional behavioral strategies. While medications and behavioral strategies might appear harmless, in certain situations they can intensify a baby’s distress and/or cause additional problems for the baby further down the track.

Antacid medications

Antacids are effective in the treatment of esophagitis. However, a baby with GER does not suffer from esophagitis. Her irritable, wakeful, fussy or aversive feeding behavior are due to other reasons. No amount of antacid medications will help to improve the baby’s demeanor if the underlying cause of her troubled behavior is unrelated to acid reflux. Treating a healthy, thriving, yet fussy, wakeful baby with medications is likely to do more harm than good. (See antacid medications for more on potential problems associated with these medications.)

Holding baby upright for 15-30 minutes after feeds

While this might reduce spitting up and thus lessen the laundry load for parents, this strategy can cause a baby to fuss owing to boredom. Alternatively, the baby might learn to associate sleeping with being held upright in a parent’s arms and as a consequence wake and cry every time she is put down. (See Sleep Associations.) If her sleep is constantly broken because of her desire to be held in arms while sleeping and the parent’s inability to hold her for as long as she needs to sleep, she will be at increased risk of sleep deprivation. Sleep deprivation is major cause of infant irritability often mistakenly attributed to acid reflux. (See Overtired Baby for signs of sleep deprivation.)

Elevating the head of baby’s bed

Once babies becomes mobile, usually around the age of 4 months, it’s often not possible to keep them in an upright position without restraining their movements in same way. This can frustrate a baby. Restraints that apply pressure around a baby’s abdominal region could also increase the risk of spitting up as she wiggles against them.

Thickened feeds

Thickened feeds are a good option for babies who throw up so much milk they fail to gain sufficient weight. They can reduce spitting up and therefore reduce laundry, but they don’t offer any benefit to a baby who is already thriving.

Switching from breastfeeding to formula

Nursing mothers are sometimes advised to stop breastfeeding and give their baby thickened formula in the hope that this will improve the baby’s level of contentment. Sadly, in the case of lactose overload (which is associated with an oversupply of breastmilk and hence irritability and spitting up) this strategy can reduce a baby’s distress. I say sadly, because the baby will be deprived of all the benefits that breastmilk and breastfeeding has to offer. In the case of lactose overload a baby's contentment can be enhanced easily and quickly once the mother makes appropriate adjustments to her breastfeeding practises.

Starting solids too soon

This might help to keep more milk down; however, starting solids before the age of 4 months is linked with an increased risk of food allergies and respiratory problems due to aspiration.

While the above strategies can be effective in reducing the amount a baby spits up, they will do little if anything to improve the baby’s contentment if the cause of her discontentment is due to other reasons.

Now compare GER with GERD.


GERD - pathologic reflux

The complications associated with GERD are: 

  1. Esophagitis
  2. Failure to thrive
  3. Aspiration

Complications due to reflux are rare. They are more common in babies and children with cerebral palsy, Down syndrome, cystic fibrosis and upper gastrointestinal malformations (trachea-esophageal fistula, hiatus hernia, pyloric stenosis). 

It is estimated that 1 in 300 babies experience abnormal signs and symptoms that warrant a diagnosis of GERD[i]. Yet, between 5-9 percent of babies receive a diagnosis of GERD[ii].


[i] Behrman RE, Kliegman R, Jenso HB, eds. Nelson Textbook of pediatrics. 16th ed. Philadelphia: W.B. Saunders, 2000:1125-6. 

[ii] Campanozzi A, Bossia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, et al. Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey. Pediatrics. 2009;123:779-83.


Signs of complications

Baby may show all of the signs described for GER with the exception that weight gain is typically poor in the case of esophagitis. Other signs are usually present.

* Repeated choking and gagging at random times.

* Distress from the painful effects of esophagitis can occur at any time but is more likely if refluxing occurs at a time when there is little milk left in the stomach, i.e. 1.5 to 2 hours after feeding.

* Extreme distress and prolonged periods of inconsolable screaming (where nothing soothes baby) occur frequently both day and night. Rarely is this distress confined to one particular time of day.

* Sleep disturbance: Short daytime naps and frequent awakenings overnight where your baby is unable to be comforted. The baby may sleep as little as 4-5 hours in a 24-hour period, only collapsing into sleep when exhausted. 

* Screaming during feedings and/or refusing to feed.

* Blood in vomit. This can be red or dark coffee color. (Check this is not due to a nursing mother’s cracked nipple.)

* Failure to gain sufficient weight or weight loss.

* Repeated coughing or wheezing.

* Repeated chest infections.

Please note: There are numerous behavioral reasons why a baby might experience poor growth, cry inconsolably, have trouble sleeping or refuse feeds; for example, underfeeding, overfeeding, sleep deprivation due to learned dependence on outside help to sleep, overstimulation, and a behavioral feeding aversion owing to being force fed.  These problems need to be assessed, by careful and thorough consideration of the parent’s infant feeding and settling practises, before assuming the cause is GERD.

When a baby is thriving, its more likely that reflux is due to GER, and distressed behaviour due to other causes. 


Diagnosis of GERD

A doctor cannot see inside a baby’s esophagus during a routine examination. Without clinic evidence of esophageal bleeding or respiratory complications, a diagnosis of ‘acid reflux’ is typically based on poor growth and the parent's description of the baby's troubled behavior.

The baby is commenced on a ‘trial’ of medications and parents are encouraged to employ behavioral strategies described above. GERD is clinically confirmed if symptoms resolve following a successful trial of medications. 

If behavioral strategies and medications prove unsuccessful, most doctors will trial a range of different medications before ordering diagnostic tests. All investigations for GERD (barium swallow, nuclear scintigraphy, pH probe and endoscopy) have considerable limitations. 

Barium swallow

The baby swallows a liquid containing barium, which shows up under X-ray. The liquid outlines the esophagus and stomach showing any narrowing. The purpose of a barium swallow is to exclude structural abnormalities or obstructions of the upper gastrointestinal tract that might cause similar symptoms to GERD. And to check whether baby is aspirating any fluids into her lungs. It will not show if a baby is suffering from esophagitis.

pH probe 

An acid sensitive probe is passed through the nose and into the baby's esophagus. This remains in place for 24 hours and records the frequency and duration or reflux episodes by measuring the pH (acid balance). However, the severity of acid reflux does not correlate consistently with symptom severity or complications.

Endoscopy and biopsy

This is the most reliable diagnostic test for GERD. An endoscope is a fine tube with a camera at the end. It is inserted into the baby’s oesophagus enabling the doctor can see if there are any signs of inflammation or ulceration and take a tissue samples. This procedure requires a full anesthetic and is rarely performed on babies due to the invasive nature.


Medical treatment of GERD

Gastro-esophageal reflux is a treatable condition. Once managed correctly it should cause a baby no further distress. 

Antacids and acid suppressing medications

Medical physicians often prescribe antacid medications as a first line approach for the treatment of suspected esophagitis. Antacid medication will not stop a baby from spitting up. They are given to neutralize and/or limit the production of stomach acid. (See problems associated with antacid medications.)

Prokinetics

There are medications that can be used to speed up the movement of stomach contents into the intestines, in doing they reduce the incidence of spitting up. They may be helpful to babies who are diagnosed as 'failure to thrive' but are not helpful to thriving babies. The benefits of these medications need to be weighed against the risk of possible side effects.

Behavioral strategies

Such as holding baby upright for 15-30 minutes; elevating the head of baby’s bed; thickened feeds; dietary changes etc. have been described above. 

Surgery

In extreme cases, where a baby repeatedly throws up huge amounts of milk and/or food and hence fails to gain weight, surgery may be necessary to tighten the sphincter that closes between the stomach and esophagus. Nissen fundoplication is the most widely used of the surgical procedures.


What every parent should know

Unfortunately, the age when babies are most likely to regurgitate stomach contents (birth to 6 months) coincides with the time when babies tend to cry the most. As a result, countless healthy, thriving babies who experience normal GER are mistakenly diagnosed and medicated for GERD.

'Reflux’ has become the most common diagnosis used to explain crying for unknown reasons, sleep disturbance and fussy feeding behavior commonly displayed by healthy, thriving babies in Western societies. Reflux has overtaken colic as the favored diagnosis for just about anything that troubles a baby.

Busy health professionals and those unfamiliar with the many developmental and behavioural problems experienced by healthy babies and/or the intricacies involved in breastfeeding, bottle-feeding and infant settling methods, will often base their diagnosis on the following. 

Crying baby + anxious parent (owing to baby’s crying) + baby throws up = reflux

OR

Crying baby + anxious parent + baby does not throw up = silent reflux.

In many cases, a diagnosis of ‘acid reflux’ will be made without the parent being asked a single question about their infant feeding and settling practises. 

Misdiagnosis of GERD occurs more often than you might expect. A misdiagnosis of GERD can cause parents to endure months of stress and worry, and hundreds of dollars searching for a medical cure for a condition their baby does not have. Worse still is that needless dietary changes and medications have the potential to cause problems for a baby further down the track.

Medications should not be used as a first line approach in the case of normal healthy, thriving babies. Rather the first step should be a thorough assessment of behavioral reasons for the baby's troubled behavior. For example, overlooking or misinterpreting baby’s behavioral cues, behavioral feeding problems that occur due to incorrect feeding technique, unsuitable equipment or parents' failure to respond appropriately to infant feeding cues; and distress due to sleep deprivation related to a baby’s learned dependence on parent’s or unreliable props or aids to fall asleep and remain asleep. 

What is important for all parents to consider is that even in the case a confirmed diagnosis of GERD (though endoscopy) this does not mean a baby is excluded from experiencing developmental and behavioral problems common to all babies. Effective treatment of GERD does not guarantee a contented baby. A number of studies have shown that medications, though effective in treating esophagitis, do little to stop a baby from crying. See Stop the PPI express: They don’t keep Babies quiet. PPI’s are no better than placebos for screaming babies.

"Too many babies receive acid reflux medications" according to Dr Eric Hassell, a pediatric gastroenterologist at Sutter Pacific Medical Foundation in San Francisco, USA.

So don’t limit your search for a solution to your baby’s distress to medical treatments. It could be that be that your baby’s troubled behavior is due to another cause. 

© Copyright www.babycareadvice.com 2003. All rights reserved. Permission from author must be obtained to reproduce any part of this article. 

Added Nov 2003. Revised Aug 2008; Feb 2014.