Reflux – what can you do?

In the last few wees I have spoken to many moms and read many blogs to do some more research about reflux in babies. (See the previous post to learn more about what reflux is). There are some interesting and scary treatments suggested out there! As a mom I wish I could give you a miracle-cure that would help your baby sleep better, cry less, spit up less. Unfortunately I know such a cure does not exist, no matter how alluring some moms on social media make it sound. As a pediatrician I would like to stick to what has been proven to work and what is safe for your precious baby now and in the long run. So here goes:

“You have to love your children unselfishly. That is hard. But it is the only way.” 

Barbara Bush, Former First Lady of the United States

General management for all babies with reflux (GER and GERD):

• Upright positioning (90°) for 20-30min after feeds.

Babywearing keeps your hands free and keeps baby happy and safe.

“Reflux pillows” that elevates your baby’s head while sleeping has not been proven to make a big difference. Please remember the safest sleeping position for a baby is flat on his back to reduce the risk of SIDS (Sudden Infant Death Syndrome).  Even though babies with reflux sleep better on their stomachs or left side down I cannot recommend this if your baby is not monitored continuously.

Placing your baby in a rocker or car seat can worsen reflux due to the scrunched up positioning and increased pressure in their stomachs.

• Feeding volume and frequency:

It helps to give smaller feeds (so that you do not overly distend the abdomen) more frequently. Working out the smaller volumes if you are bottle feeding also prevents over-feeding and unhealthy weight gain.

Breastfeeding moms can feed on demand, but try to help soothe baby in other ways (baby-wearing, sucking on your fingers or a dummy) if the previous feed was less than two hours ago so that you do not worsen the reflux symptoms. Breast milk has a protective effect against reflux, so you are doing a great job!

• Thickening of feeds.

Studies have proven that this can decrease the episodes of spitting-up, but it is a very laborious process. Formula or expressed breastmilk can be thickened with rice or oat-porridge or Maizena.

• Trial of a milk-free diet.

If you are breastfeeding, you can cut out all dairy and beef products from your diet for 2 weeks to see if there are any change in symptoms. You might have to cut out soy-products too. If this reduces the reflux your baby probably has an allergy and not pure reflux.

If you are formula feeding, you can try a trial with an “extensively hydrolyzed formula” (also called hypo-allergenic such as Neocate or Similac Alimentum). It is not recommended to change to a soy-based/ goats-milk based / lactose free formula for this trial as there can be a cross-reaction to the allergens. Once baby is diagnosed with a milk-allergy you can try these substitutes under guidance of your doctor and dietitian.

• Avoid exposure to tobacco smoke as this can further decrease the pressure in the lower esophageal sphincter (see previous post), causing more frequent episodes of reflux.
• Adding probiotics has been suggested but there is not enough evidence to prove if it will help.
• The use of a Chiropractor is not recommended as most of their procedures are not evidence based. “Subluxations of the spine after birth” mostly cannot be proven, will not cause reflux and the interventions they apply are either too delicate to really change anything in the bony structure, or too rough to be safe for the developing spine of your child. Please be careful.

If you have tried all of these tips and your baby still shows signs of GERD (as discussed previously) you can discuss the following steps with your doctor:

1. Is it really GERD?

Many diseases can mimic reflux and will not respond to reflux medications:

• Cow’s milk-protein allergy: this is a type of food allergy that can best be diagnosed by an exclusion diet.
• Eosinophilic esophagitis – this is inflammation of the esophagus due to an allergic reaction involving a specific type of white blood cells. These babies can have trouble swallowing, vomiting and chestpain. Diagnosed by a biopsy during an endoscopy.
• Anatomic abnormalities of the esophagus – sometimes there is a connection between the esophagus and trachea (air pipe), or a web of veins causing a partial occlusion of the esophagus. This can be diagnosed with the help of a contrast swallow.
• Celiac disease – allergy to gluten causing inflammation in the esophagus, stomach and intestines, can also have many other symptoms. Diagnosed with an exclusion diet and can be confirmed with a blood test.

As you can see an endoscopy (looking at the esophagus and stomach from the inside with a camera, your baby will need sedation or anesthesia) can help to clarify the diagnoses. It can also evaluate for inflammation and check the response to treatment with PPIs.

Another diagnostic test often used is Ph monitoring where the height of the acid reflux and the amount of episodes over 24hours are tested. Because reflux can also happen in normal infants this test cannot give us a definitive answer.

2. Does my baby need acid suppressing medication?

PPIs (Proton Pump Inhibitors for example Nexiam, Losec) are used to suppress the amount of acid formed in the stomach. It will NOT decrease the number of reflux episodes or the amount of vomiting, but it could make your baby more comfortable if there was inflammation and pain due to the acid.

The acid in your stomach is actually very important for your baby’s digestion and immune function, and decreasing the acid content certainly does have risks.

Who should get PPIs and for how long ?

• Babies with proven esophagitis seen on endoscopy (use for 3-6months and then re-asses)
• Babies with severe symptoms of GERD that does not respond to conservative measures can be given a trial of two weeks. If there is a definitive improvement medication can be continued for 3-6months and then re-assessed.

Possible complications of PPIs:

• Higher risk of acute diarrhoea and pneumonia because you remove a line of immunity defence. This can also lead to infection of the gut with Clostridium Difficile.
• Interferes with the absorption of Iron and Vitamin B12 and lead to anemia (low red blood count).
• Can affect calcium absorption and lead to increased risk for fractures.
• Allergic sensitization – there is a link between using acid suppresion in infancy and later development of allergies.

When you want to stop the PPI, it is important to wean it slowly as there can be a rebound higher acid production for the first few days after stopping the medication.

The beginning of wisdom is this: Get wisdom. Though it cost all you have, get understanding.

Prov 4:7

3. Are there other medications that could help?

• Antacids such as Gaviscon have been shown to provide some relief in the symptoms of reflux. It works by coating the stomach contents with an alkaline layer which makes it more difficult to push back and less painful to the esophagus. It can be used in the place of thickening feeds in breastfeeding babies. Although there are not a lot of studies done in babies, it seems safe to give for short periods (less than two weeks) or on occasion. Using it for longer periods could lead to aluminium toxicity or rickets (Vitamin D deficiency).
• Prokinetics such as Domperidone (Emex), metoclopramide or erythromycin could help to speed up the passage of feeds through the esophagus and stomach. They could however have many unpleasant side-effects affecting your baby’s movement, brain and heartrate.

4. Will surgery help?

Surgery is usually not indicated in children under 1 year of age. Even in older children and adults the results of a Fundoplication surgery are not very satisfactory.

If you have read all the way to here you must truly have many questions! I hope that I could give you some answers, some advice and some hope. Remember that you are not alone. Talk to other moms and share the burdens and the joys. Talk to your doctors and walk the road with them, they want to help you. These days feel long, but the years are short and before you know it your child will be waving goodbye on their first day of school (without vomiting all the milk from their morning porridge)!

1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M; “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)”; J Pediatr Gastroenterol Nutr. 2018 Mar; 66(3): 516–554. ; doi: 10.1097/MPG.0000000000001889
2. Rybak A, Pesce M, Thapar N, Borelli O; “Gastro-Esophageal Reflux in Children”; Int J Mol Sci. 2017 Aug; 18(8): 1671; Published online 2017 Aug 1. doi: 10.3390/ijms18081671
3. Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, Barbera C, MagazzùG, Pettoello-Mantovani M, Staiano A; “Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey.”; Pediatrics. 2009;123(3):779.
4. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group ; “Gastro-oesophageal reflux disease in children: NICE guidance”; BMJ. 2015;350:g7703. Epub 2015 Jan 14
5. https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408
6. Safe M, Chan WH, Leach ST, Sutton L, Lui K, Krishnan U; “Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe?”; World J Gastrointest Pharmacol Ther. 2016 Nov 6; 7(4): 531–539.; doi: 10.4292/wjgpt.v7.i4.531