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After two babies with reflux and CMPA (Cow’s Milk Protein Allergy), I was hoping for a more settled time with my third baby. Not only did my third baby have reflux, but she had the most significant reflux out of all my babies and dairy elimination did not completely resolve her symptoms. Note that CMPA is not implicated in all reflux cases. All my babies had ‘silent reflux’ which is explained further down.

It can be really worrying when your baby has reflux, especially if they have slow weight gain or signs of discomfort. I have written this post to share some of my own experiences alongside further useful information on reflux. I have written a separate post to cover CMPA.

 

What is infant reflux?

 

Infant reflux is when milk/food comes back up from the baby’s stomach into the oesophagus (food pipe). This may or may not cause the baby to bring milk up out of their mouths or be sick. Silent reflux is the term used when there are signs of reflux but baby does not bring the milk up out of their mouth.

Reflux is also referred to as gastroesophageal reflux (GER) and affects 4 out of 10 babies younger than 1 year. It usually starts before 8 weeks of age and resolves by 12 months.

Is infant reflux the same thing as colic?

No, reflux is not colic. Colic is when a baby cries a lot but there is no obvious cause, whereas reflux is a specific condition with a known cause.

 

reflux-vs-colic

What are the signs of infant reflux?

Infant reflux symptoms include:

 

  • Bringing up milk during or after a feed
  • Unsettled with feeding
  • Coughing or hiccups associated with feeds
  • Crying
  • Poor weight gain
  • Swallowing or hearing gulps later after feeding has finished
  • Disliking lying flat with a preference for being upright
  • Back arching posturing (also known as Sandifer’s Syndrome)
  • Hoarseness

Why do babies get reflux?

 

There is a ring of muscle called a sphincter between the oesophagus (food pipe) and stomach which stops backflow of food. In babies, normal “physiological” reflux occurs because this sphincter is not fully mature yet. This means that stomach contents can more easily flow back up the oesophagus.

Babies can reflux multiple times a day without causing any problems. Time is your best friend here, as reflux symptoms improve as baby grows and the sphincter matures so that it will open when baby swallows, but stay tightly closed at other times. This is the case for the majority of babies with reflux.

illustration-of-infant-reflux

Sometimes, reflux may have another cause such as Cow’s Milk Protein Allergy. Rarely, reflux can be a sign of another medical problem. Please see your doctor if you have any worries about your baby’s reflux, or if you are concerned about any other symptoms. Examples of other symptoms for review are not limited to, but include:

 

  • Excessive or projectile vomiting (note that normal reflux in babies can happen more than 6 times a day)
  • If the vomiting has blood or coffee-coloured bits, or is yellow or green
  • Loss of weight or slow weight gain
  • Changes in baby’s stools (poo) such as presence of blood or mucus, change in colour or consistency
  • Refusing to feed
  • Distressed / inconsolable crying or more lethargic than usual
  • Develops reflux symptoms after the first 6 months
  • Has a swollen or tender tummy
  • Appears dehydrated
  • Has a fever/ feels hot
  • Difficulty breathing
  • Has a chronic cough
  • Still has reflux at age 1

How is infant reflux diagnosed?

Infant reflux is diagnosed on clinical history and examination. There is usually no need for any investigations if baby is content and growing well.

Further tests would depend on the history and examination. Examples of tests that may be performed include, but are not limited to:

 

  • Blood and urine tests (to check if there is another cause for excessive vomiting or poor weight gain)
  • Ultrasound (to check for another cause of excessive or projectile vomiting)
  • XRAYS (to look for signs of a digestive tract issue)
  • pH monitoring (measures acidity)
  • Endoscopy (so that a sample of tissue from the oesophagus lining can be taken and sent for examination)

Managing infant reflux

 

Conservative measures are usually first suggested. Medication may be advised in cases were symptoms are severe. In time, the sphincter will mature and these measures can be relaxed.  Surgery (called a fundoplication) is reserved for very severe cases. Management options may include:

  • Holding baby upright for at least 30 minutes after a feed – the longer the better
  • Feeding in a more upright position (I found the rugby-hold position helpful with the use of a breastfeeding pillow underneath to support a more upright position)
  • Prone positioning/ “tummy time” and left-lateral positioning (lying on the left side) when awake may be better tolerated than lying flat on the back. Baby should be put to sleep on their back
  • Sometimes it may be recommended to have a slight incline but you should not put pillows into the cot to create an incline. We had the Chicco Next2Me Side Sleeping Bedside Crib which has an incline feature.
  • Smaller, more frequent feeds (with the aim to have the same total intake as before). Breastfed babies are likely to do this anyway. My babies fed 2 hourly for months
  • Stopping a feed mid-way to burp baby
  • Eliminating dairy (and also sometimes soya) products from your own diet if breastfeeding, or a trial of a different formula for babies with CMPA if formula-fed to see if it makes a difference
  • Changing the type of infant formula if baby is formula fed
  • Changing the type of teat on a bottle to avoid swallowing too much air
  • Breastfeeding support to check positioning, latch, and other tips to avoid swallowing too much air. Oversupply and fast-let-down may exacerbate spitting up so it may be helpful to seek advice from an IBCLC Lactation Consultant. Allowing baby to finish one breast completely before switching sides may be helpful. KellyMom and La Leche League are useful resources for breastfeeding and will also cover these topics
  • A short trial of medicine may be advised if conservative measures have not helped, such as alginates (e.g. Gaviscon) or an acid-reducing medication (e.g. omeprazole)
  • Weaning onto solids at 17 weeks may be advised in some cases
  • If symptoms are severe, a referral may be made to a paediatrician to further assess, which may also involve dietician input to consider high calorie feeds and further support with weaning onto solids

 

Do I need to stop breastfeeding?

 

No, you don’t need to stop breastfeeding. You may be advised by well-intentioned friends or family that formula milk will stay down better but this is not correct. In fact, studies have shown breast-fed babies are less likely to get reflux. Breastmilk also leaves the stomach quicker than formula milk

 

My own experience

 

I found positioning measures the most helpful and the most improvement for me was seen when they were weaned onto solids (eldest son started solids at 5.5 months, next baby at 4.5 months, and the youngest at 17 weeks). Unfortunately Gaviscon didn’t help and my youngest had a trial of omeprazole for 4 weeks.

My children were all noted to have tongue-tie when examined, but this had been released at 8 weeks for my first baby and the day following birth for my second and third baby.  It improved latch significantly but there was no change with the reflux symptoms. I also had fast-let down so I needed to change breastfeeding position to help with that.

The best thing I did to ease symptoms was use my sling. That’s why I keep going on about it. Unless I was planning to sit down for a while, I would put her in after her feed too to keep her upright afterwards. This meant I could carry on with my tasks, help my younger children, and she was so settled. She rarely cried when she was in her sling. See my post Babywearing: Rocking The Stretchy Wrap Sling” for more on that. I tried to do lots of tummy time during the day at other times.

We didn’t use the car unless we absolutely had to. Our children absolutely hated it. The position baby assumes in order to go into the seat seems to put some pressure on the stomach and can make reflux symptoms worse. I would try to avoid travelling in a car soon after a feed.

My boys both had glue ear requiring treatment, which is interestingly associated with reflux as a risk factor. I am not sure how much reflux would have contributed though as my youngest with the most severe reflux has had no hearing concerns.

Ultimately, it all eventually got better.

 

I’d love to hear your thoughts and if you found this post useful, please share!

References

1) Chen PL, Soto-Ramírez N, Zhang H, Karmaus W. Association Between Infant Feeding Modes and Gastroesophageal Reflux: A Repeated Measurement Analysis of the Infant Feeding Practices Study II. J Hum Lact. 2017 May;33(2):267-277. doi: 10.1177/0890334416664711. Epub 2017 Jan 20. PMID: 28107099.

2) Heacock HJ, Jeffery HE, Baker JL, Page M. Influence of breast versus formula milk on physiological gastroesophageal reflux in healthy, newborn infants. J Pediatr Gastroenterol Nutr. 1992 Jan;14(1):41-6. doi: 10.1097/00005176-199201000-00009. PMID: 1573512

3) Van Den Driessche M, Peeters K, Marien P, Ghoos Y, Devlieger H, Veereman-Wauters G. Gastric emptying in formula-fed and breast-fed infants measured with the 13C-octanoic acid breath test. J Pediatr Gastroenterol Nutr. 1999 Jul;29(1):46-51. doi: 10.1097/00005176-199907000-00013. PMID: 10400103.

 

 I’d love to hear your thoughts and if you found this post useful, please share!

 

MedicMum101
MedicMum101

Amal is a paediatrician and mum/step-mum to four wonderful children. She started MedicMum101 to share tips and experiences on all things motherhood. She enjoys writing about parenting, health, and wellness, as well as other life musings from time to time. When she is not working, writing, or running after the kids, you can often find her working on a new piece of art.

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