Reflux

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What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

What Is Reflux?
Reflux is the word used to describe what happens when the stomach contents come back up into the gullet or into the mouth.

The medical name for gullet is oesophagus (spelt esophagus in the US) So the long name for reflux is gastro-oesophageal reflux disease, shortened to GORD in the UK and GERD in the US.

The diaphragm is the muscle which separates the chest cavity from the abdominal cavity. As the oesophagus passes through the diaphragm, the diaphragm acts like a valve – stopping stomach contents from going backwards up the oesophagus. Doctors refer to this valve mechanism as a sphincter. (see diagram below)

Sometimes the valve action isn't as strong as it could be. In babies it is because the sphincter action of the diaphragm isn't fully developed. During the first year of a baby's life, the sphincter action gradually gets stronger and their chance of having reflux decreases.

Around half of all babies will get reflux to some degree, but in only a small percentage of these is it a real problem. At the age of 10 months the number of babies still showing any signs of suffering with it is down to about 5%.



What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

Symptoms:
Your baby may regurgitate a little milk after a feed or have hiccups. He/She may occasionally cough a little after regurgitating the milk if a little has gone “down the wrong way”. This is normal and as long as your baby is otherwise well, you don't need to worry.

In some cases however, the regurgitation may be more regular and larger in volume and baby may be distressed by this, or in the case of so-called Silent Reflux, baby may not regurgitate at all but still have reflux symptoms.

Both formula-fed and breastfed babies may be affected. See below a list of the more common symptoms of reflux:

  • Crying in pain
  • Discomfort when feeding (arching, screaming, refusal, turning away)
  • Fussiness
  • Runny nose
  • Frequent vomiting or spitting up
  • Foul breath (smells acidic)
  • Chronic Cough
  • Night-time cough
  • Poor sleep habits, frequent waking
  • Wet burps
  • Hiccups
  • Comfort feeding- constant feeding to alleviate pain
  • Food intolerances
  • Hoarse voice, sore throat
  • Poor Weight gain

Less common symptoms of reflux:

Aspiration
Recurrent pneumonias
Ear/nose/throat/sinus infections

These are only some of the symptoms of reflux. Infants with reflux may experience any number of these symptoms. If you have a baby which is exhibiting any combination of these symptoms, I would seek advice from your GP or Health Visitor initially.

It's important to realize that not all babies with reflux will require medication or have difficulties with their reflux. Many infants, usually called happy spitters, will benefit greatly from some simple steps that you can start trying right now. Many of the things listed below will help with your baby's discomfort and spitting up, eliminating the need for medication.

What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

Coping with reflux

The most important thing to remember is coping with reflux is 'managing reflux'. This means not letting it get the better of you or your baby! It might help to imagine the reflux is a big bottle of bubbling liquid waiting for any opportunity to spill out all over you: this way you can easily see in your mind what things might going to 'bubble it over' - too much liquid too soon, lying flat, being jiggled around etc...

Positioning with Feeds
Keeping the baby upright during and for at least 30 mins after a feed can help to reduce reflux by allowing gravity to work at holding the feed down. Aim to keep as motionless as possible using the after feed time as quiet time. Gentle movements, perhaps being worn in a sling or being pushed in a buggy may work well, as long as an inclined position is observed. Formula fed babies may require longer periods of settling, since formula is digested slower than breastmilk.

Sitting & Sleeping
For a comfortable seated position, try to find a soft seat or firm, cradling beanbag and for sleeping positions look to use a wedge to maintain a consistent raised position. As with positioning after feeding, keeping baby propped during sleep is essential when they have reflux. It can help reduce painful reflux episodes and reduce the risk of aspiration. It is highly recommended that all babies sleep on their back because it has been shown to reduce the risk of SIDS. This is fine for babies with reflux as long as the baby is safely propped up to at least 30%, we found the higher baby is propped the better. Having said that, many babies with reflux prefer sleeping in the prone position (stomach), also elevated of course, and may have less reflux episodes in this position. Discuss this with your doctor and he can help decide if it's okay, and how to safely manage allowing baby to sleep in the prone position. It's very important to discuss this with the doctor before trying it as babies with reflux are already at an increased risk of SIDS.

For reflux babies, it's a question of weighing up what works for you and baby.

It is not advised to place a baby face down on any foam or bedding product without seeking advice first from a health professional.

Car Journeys
Most car seats and travel systems have a deep ‘well' for one static seated position with baby slumped in an uncomfortable position. When baby slumps and slouches over like this added pressure is placed on their tummy and the baby will feel the pain of rising acid. This pressure can be very painful and can increase reflux episodes. Parents of babies with severe reflux report that car journeys would promote more sickness than days when they stayed at home.

Look for a car seat that allows multiple positions of recline/incline for baby to be inclined enough that they are fairly upright withut being slouched. Car seats have a range of options nowadays and incline seems pretty standard. You can use a booster cushion which will help with not just the car seat but also, buggy, swing, high-chair etc. The extra padding gives just enough support to the mid section to promote comfort and in some cases has reported to actually reduce vomiting.

Carrying
Try carrying baby around as much as possible in a baby carrier throughout the day. Carried babies tend to cry less and crying will make reflux worse, plus, it keeps baby upright. Try looking at baby slings or wraps: there are also many different ways of carrying or wearing a baby. Decide what works for you and baby.

Clothing
Avoid tight clothing, particularly clothing that is tight around your baby's tummy, can make reflux worse by increasing pressure on the lower oesophageal sphincter . Make sure baby stays in loose fitting, elastic waists whenever possible. Also ensure that nappies are not tight around the tummy and if it suits, buy bigger for comfort.

What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

Feeding:

Formula fed babies get more reflux, firstly because breast milk is digested twice as fast as formula, and secondly because it is a natural human substance. If your baby is already formula fed when you establish that they have reflux, then a change of formula can sometimes help – if the baby has a cows' milk protein allergy or lactose intolerance, then giving the baby a normal cows milk based formula can make reflux worse. Discuss this possibility with your health visitor or doctor if you are worried about an intolerance.

If you are breastfeeding, try eliminating the foods that can make reflux worse. Dairy products are a big offender, as is caffeine, fatty foods, spicy foods, citrus fruits. If eliminating these things seems to help, you can slowly (about one thing a week) start to introduce one thing at a time back into your diet and watch baby's reactions. This will help give you an idea of exactly what was making the reflux worse, so that you (hopefully) don't need to give up everything you love, just one or two things.

An article written by Laura Barmby in New Beginnings magazine states,

"Breastfed babies seem to cope better with GER than artificially fed babies. During breastfeeding the motion of the baby's tongue triggers peristaltic waves along the gastrointestinal tract (Lawrence 1994). These muscular contractions help to move the food down into the stomach and on to the small intestine. Human milk digests more completely and almost twice as fast as formula. The less time the milk spends in the stomach, the less opportunity there is for it to back up into the oesophagus. In addition, breastfed babies are generally fed in a more upright position than artificially fed babies, and gravity may help to keep the milk and gastric acid in the stomach where they belong."

Thickening
Some babies with reflux will respond well to thickening substances introduced into their feeding regime. The added weight of the thickener either in the milk or given after the feed helps to keep the food from splashing around in the baby's tummy and can help to keep it down.
In the UK Infant Gaviscon is generally prescribed, but speak to your doctor before putting any thickeners into your baby's feed. There are also some specialist formula milks which are pre-thickened, however speak to your GP before exploring these as they differ in their base compounds.

Feeding Time
When and how much a baby is fed can also have an impact on their reflux. Smaller more frequent meals through out the day can work much better than larger, less frequent meals. Also, avoid feeding baby right before bedtime, particularly if the baby is already a poor sleeper. Ideally keeping baby upright a minimum of 30 minutes after each feed, so give yourself time to settle down in the night times. Some Mums also recommend lying baby on THEIR left side after a feed as it aids digestion and settles baby quicker. The key to managing reflux and keeping milk down is positioning. Make sure you give yourself enough time to give a relaxing feeding experience and settle into a good upright cuddle afterwards. If you are in a hurry, baby will pick up on your anxiety, especially if they themselves are anxious about any reflux pain they may associate with feeding.

Burping & Soothing
Stopping to burp baby frequently (at least after every 2 ounces) during feedings can help, providing baby doesn't become agitated by the interruptions. Sucking on a dummy can increase saliva production, which as an alkaline can help neutralize some of the acid that may come up.
Try infant massage, it's been shown to improve digestion and will help relax baby too.

Remember, what works for some babies doesn't always work for others: don't be too concerned with trying to get into a ‘routine' with feeding and sleeping. A baby suffering from reflux can have random good and bad days, so until you start to see a pattern in medicines working or positioners helping, let the baby dictate for as long as you can manage.

What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

Silent Reflux

'Silent' Reflux is a less common type of reflux which occurs with no visible regurgitation, however the stomach's acid still travels up into the oesophagus, particularly when the baby is being laid down flat. A persistent cough and sore throat may also contribute towards diagnosis, as the acid may reflux up from the stomach into the oesophagus and the airways.

Silent reflux is one of the most difficult conditions to diagnose and sometimes the baby's consistent painful reaction to being laid flat and inability to settle at sleep times, is the first indication that something is occurring. If you think you may have cause to consider silent reflux, think about putting baby in an elevated sleeping position. A baby wedge or bed blocks should be a good start. You may notice a difference immediately.

Another sympton is constant feeding especially in silent reflux, as babies feed to keep the acid washed down: this often means that failure to thrive is a missing symptom, as the constant feeding means weight gain is good.

I f your baby has other symptoms of reflux too: a little cough, hoarse crying, bad breath, arching of back and struggling during a feed, then it may be worth visiting your GP.

If you have genuine concerns about your child and your health care providers don't seem to be listening, then you are within your rights to ask for a second opinion: many health professionals are ignorant of reflux and silent reflux, as it is a relatively recently discovered phenomena, and they may have qualified before before it became something that they would automatically receive training in.

What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux

Medical Management

Gaviscon

Gavsicon Infant contains two active ingredients, sodium alginate and magnesium alginate. These are naturally occuring substances that are found in a particular type of seaweed. Alginates act locally in the stomach to physically prevent the contents of the stomach from flowing back into the food pipe (reflux) and being regurgitated.

Some babies are particularly susceptible to this regurgitation or reflux, especially if they are very hungry prior to a feed or swallow more air than normal as they feed. In some babies it is merely the appropriate response to overfeeding. It is no cause for concern if the baby is happy, feeds well and gains weight, and normally resolves itself as the infant starts to eat more solids and spend more time in an upright position.

Sometimes though, if the baby is not gaining weight properly or has complications of the reflux, this medicine may be recommended by a doctor or pharmacist. It may also be recommended if the child has a hiatus hernia that is causing the reflux. It should only be given on the advice of a medical professional.

The active ingredients of Gaviscon infant are not absorbed into the bloodstream. Instead they work by reacting with the stomach contents to form a gel. This gel thickens the stomach contents, making it more difficult for them to be refluxed back into the food pipe and be regurgitated.

See also our section on Specialist Infant Formulae for formulae whose ingredients thicken in the stomach.

Domperidone - to follow, please check back

Ranitadine (Zantac)- to follow, please check back

Here is an external link to a page of Reflux Medications just until we have more info here.

What is Reflux? - Symptoms of Infant Reflux - Coping With Infant Reflux - Feeding - Medical Management - Silent Reflux