By Carol Smyth – Ballyclare, IBCLC, Northern Ireland

If you have a new baby, it is likely you’ve heard about reflux or gastro-esophageal reflux disease (GERD). Many mothers worry about whether their baby could have GERD if they are crying or unsettled. You may know other babies who are on medication for reflux. Are large numbers of babies really producing excess acid? It is common that many symptoms attributed to reflux are signs of a feeding issue, and have non-medical solutions.

Reflux, or gastro-esophageal reflux, is common and physiologically normal. It describes the passage of any gastric contents into the esophagus. Each time we burp, we reflux. Reflux happens to us all frequently. The word “reflux” however, has become confused with GERD (reflux disease). It has become associated with a baby who is vomiting, posseting (regurgitating milk after feeding), waking frequently, wanting to be held often, or not wanting to lie alone. Western society has started to confuse reflux with other issues and behaviors.

These behaviors are assumed to be due to pain from stomach acid, and many babies are prescribed medication to reduce the production of that acid. These are effective drugs, but reducing acid has an effect on digestion and immune function. Research has shown that babies taking these drugs are at higher risk of infections, allergies, and even bone fractures. [1,2,3] Research also suggests that they do not reduce fussiness or crying in babies – which would suggest that the fussiness and crying may be unrelated to acid production. [4,5,6]

What are the causes of the symptoms often associated with reflux?

1. Normal baby physiology – Babies have little core strength and many spend a lot of time horizontal. They have a liquid diet and can have an immature valve closing the top of the stomach, so it is leaky.

2. Too much milk too quickly – Babies are designed to drink small amounts frequently. A baby feeding every three hours needs to drink twice as much at each feed as a baby drinking every one hour and a half. Overfilling the stomach causes it to stretch, loosening the valve at the top of the stomach – allowing the overflow to escape. Frequent feeding can reduce reflux episodes.

3. Aerophagia – This just means swallowing air. A baby who is gulping or spluttering may be taking in more air than they should. A poor latch, scheduled feeds, oral restrictions or difficulty managing flow can all cause excess air to be swallowed. The stomach valve will then open to allow it to escape. As air comes back up, milk escapes too. Correcting the feeding issue so that air isn’t swallowed can reduce or eliminate reflux.

4. Low milk intake – Poor weight gain is sometimes diagnosed as “silent reflux” but the most common cause of poor weight gain is lack of milk. When the flow of milk is slow, it is very common for a baby to arch, pull on and off the breast and cry in frustration. Resolution would be to increase milk supply and ensure baby is drinking effectively.

5. Allergies/intolerances – When reflux occurs in healthy babies, it is generally painless. Babies are on a milk diet (which neutralizes acid) [7] and the esophagus has a number of defense mechanisms against acidity, [8] so spitting up is usually comfortable or only mildly upsetting for the baby.
A minority of babies, however, do become very distressed when refluxing. Allergies can cause inflammation within the body, and cause pain where a non-allergic baby would experience none. Removing the allergen in the breastfeeding parent’s diet allows the inflammation to resolve and for the reflux to become normal physiologic, pain-free reflux again.

6. Unhealthy gut microbiome [9] – A healthy gut microbiome should allow for easy digestion and the production of gas that is reasonably comfortable and easy to pass. A gut microbiome which has more pathogenic species however, may cause issues with bloating, constipation, and straining. That constipation and straining can cause reflux due to abdominal pressure.

7. Physical separation between nursing parent and baby – A baby is extremely immature at birth, with a nervous system reliant on adult regulation. If a baby is not in contact with an adult, digestion does not work optimally.
We may have been primed to believe that we need to set a baby down after feeding because it would spoil our babies, but separation from us causes distress and can lead to vomiting and crying. This may explain why baby wearing (carrying a baby in a soft carrier with direct body contact) also seems to help with reflux.

 

Some babies do have GERD. These are very unhappy babies and they may need medication, but they are in the minority. Most families can be helped by a thorough look at feeding and baby care, at stress and coping strategies. Reflux is about a lot more than what happens in the stomach. Our babies deserve to have someone take the time to investigate their distress.

 

Carol Smyth is an International Board Certified Lactation Consultant (IBCLC) and Cognitive Behavior Therapy (CBT) practitioner working in a busy private practice in Northern Ireland.

She is married with two children (both breastfed). Her interest in reflux began when her first son was treated for reflux in his early weeks.  After getting some good feeding support and learning more about brain development, she realized that many of the symptoms had been misinterpreted, or improved with small changes in feeding and care. This inspired her to change careers, retrain as an IBCLC and write Why Infant Reflux Matters   – which is an evidence based self-help guide for parents and practitioners.

She is driven by a passion to minimize the gap between our understanding of normal baby behaviors and societal norms, through education and supporting parents. Understanding the level of anxious distress parents can feel when they have an unsettled baby, she uses CBT (Common Cognitive Therapy) techniques to lower anxiety alongside practical strategies to reduce reflux and the associated stress.

References

1. Laura Malchodi, Kari Wagner, Apryl Susi, Gregory Gorman, Elizabeth Hisle-Gorman,  Early acid suppression exposure and fracture in young children, Pediatrics July 2019; 144(1):e20182625. DOI:10.1542/peds.2018-2625

2. Heidelbaugh JJ. Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications. Therapeutic Advances in Drug Safety June 2013; 125-133. DOI:10.1177/2042098613482484

3. Trikha, A., Baillargeon, J. G., Kuo, Y. F., Tan, A., Pierson, K., Sharma, G., Wilkinson, G., Bonds, R. S. Development of food allergies in patients with Gastroesophageal Reflux Disease treated with gastric acid suppressive medications. Pediatric Allergy And Immunology 2013; 24(6):582-588.

4. Rachel J. van der Pol, Marije J. Smits, Michiel P. van Wijk, Taher I. Omari, Merit M. Tabbers, Marc A.Benninga. Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review. Pediatrics May 2011; 127(5):925-935. DOI:10.1542/peds.2010-2719

5. Susan R. Orenstein, Eric Hassall, Wanda Furmaga-Jablonska, Stuart Atkinson, Marsha Raanan. Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial Assessing the Efficacy and Safety of Proton Pump Inhibitor Lansoprazole in Infants with Symptoms of Gastroesophageal Reflux Disease. The Journal of Pediatrics 2009; 154(4): 514-520.e4.

6. David John Moore, Billy Siang-Kuo Tao, David Robin Lines, Craig Hirte, Margaret Lila Heddle, Geoffrey Paul Davidson.  Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. The Journal of Pediatrics 2003; 143(2):219-223.

7. Mitchell DJ, McClure BG, Tubman TRJ. Simultaneous monitoring of gastric and oesophageal pH reveals limitations of conventional oesophageal pH monitoring in milk fed infants. Archives of Disease in Childhood 2001; 84:273-276.

8. Orlando, R. C. ). The integrity of the esophageal mucosa. Balance between offensive and defensive mechanisms. Best practice & research Clinical gastroenterology 2010; 24(6):873-88.

9. Jiang et al. Gas Production by Feces of Infants. Journal of Pediatric Gastroenterology and Nutrition May 2001; 32(5):534-541. https://journals.lww.com/jpgn/Fulltext/2001/05000/Gas_Production_by_Feces_of_Infants.9.aspx