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Pharmamum’s Ultimate Guide: Reflux in babies
As I reflect back to the time both my girls were newborns, my experiences with them were very different especially when it comes to reflux. My eldest daughter, I cannot remember her ever bringing up or vomiting any milk and I clearly remember my sister, a mother of twins saying to me, ‘You don’t realise how lucky you are that Sophie is not a ‘chucky baby’. Those words did come back to haunt me when my youngest daughter was born, because my luck did run out, as Georgia was a very ‘chucky baby’. After most feeds, a small portion of milk would come back up, with no sign of it causing Georgia any discomfort. I think it bothered me more than it bothered her, in terms of the inconvenience of cleaning and extra washing I had to do. However as she got older, the frequency of regurgitation reduced and by the age of one, they were few and far between. In this blog I aim to discuss reflux, what causes it? What makes it worse? How simple lifestyle modifications can make a huge difference as well as pointing out signs and symptoms of when to get help.
All babies are born with weak oesophageal muscles above their stomach, that can easily open and allow milk to rise up and out of a baby’s mouth. It is a normal process which will resolve itself usually by the time a baby is 12 months old. Some babies regurgitate more frequently than other babies but as long as the baby is not bothered by it, there is no reason to be concerned. Often parents worry saying, ‘My child is bringing up most of their feed’. Often the amount bought up does look more than it really is, and if your baby is slowly putting on weight and developing normally, there is no medical problem. Just remember your baby’s digestive system is still immature and developing, and getting use to different quantities of milk in their ‘little tummies’. If the muscle relaxes for a split second some milk can escape and come out of the mouth. Slowly that muscle will strengthen and the frequency of ‘spill ups’ will reduce. However there are times to be concerned and need to be seen by the GP for any of the following signs or symptoms:
- has blood in the vomit
- coughing and/or wheezing
- refusing feeds
- irritability and arching their backs before or after vomiting
- extremely difficult to settle
- weight loss and crossing percentiles
The following are some simple lifestyle measures to help reduce reflux:
- If breastfeeding, try and position your baby in a more upright position. Experiment with how you hold your baby whilst you breastfeed and you may find the under arm hold ie the ‘football hold’ may work better for a baby with reflux.
- If bottle feeding, also position your baby in a more upright position. Sit them up and burp them every 2-3 minutes.
- When burping, a good position is placing their diaphragm over your shoulder(obviously whilst supporting their neck), this will apply pressure up and force any trapped air, making it easier for your baby to burp.
- Elevate the head of the cot by 40 degrees, this is shown to be of great benefit.
- When bottle feeding, ensure the baby is not swallowing air, constantly check the teat is full of milk and when preparing the formula don’t shake so vigorously like you are making a milkshake. Tap the bottle prepared, on the bench a few times to settle any bubbles before giving formula to your baby.
- Frequent feeding may make it easier for your baby to digest smaller volumes of milk. There are times when your baby will cluster feed and it is recommended if breastfeeding to remain on the one side and avoid swapping to the other breast each time. This is to avoid your baby ending up with a high lactose load. It is usually recommended to swap sides when breastfeeding however if you are feeding more frequently ie less than 3 hourly, try to feed on one side until it is empty and then switch, as the composition of breastmilk changes from the beginning of the feed to the end. The initial composition of breastmilk will consist of water and a high lactose load. This will quench the baby’s thirst and as the feed goes on, the fat content of the milk will rise. Staying on the one breast until you feel it is mostly empty, will ensure your baby, not only consumes the thirst quenching part of the breast milk, but also the higher fat content which will satisfy their hunger and keep them full for a longer period of time.
- Try and change your baby’s nappy before feeding, it is better not to raise the legs after a feed as it will apply pressure to the oesophageal muscle.
- Baby slings/carriers have been shown to help as they keep the baby in an upright position and allow gravity to keep the milk down.
- Caffeine- A small amount of caffeine is fine when breastfeeding but if your baby is showing reflux symptoms, it may help to reduce or eliminate caffeine.
- Reflux occurs in two thirds of babies
- Both breast fed babies and formula fed babies can have reflux
- It is estimated that 65‐85% of premmie babies suffer with reflux
- Reflux peaks at 4 months of age
- Spitting up is normal upto 4 times a day
- Silent reflux is when the the stomach content comes part way up the oesophagus and often either doesn’t make it up all the way up to the mouth or the baby swallows the contents and can be harder to diagnose.
- After lifestyle measurements have been tried, the first line of treatment is to try a thickened formula or formula thickeners. There are both commercially available thickened formulas in Australia (eg. Karicare Aptamil AR and NAN A.R) as well as a powdered thickener (eg.Karicare Aptamil feed thickener) that you can add to express milk or the formula your baby is used to. Just remember the teat you are using may need to be changed to one with a variable flow, as they can get clogged with the thickener.
Some parents notice that whether they are breastfeeding or formula feeding and trying the above recommendations, their baby is still very miserable, bringing up a lot of milk and even arching their backs in pain. After a lot of discussion with their maternal health nurse, doctor and/or paediatrician, a milk allergy may be suspected. About 40% of infants referred for specialist management of reflux symptoms have allergy to cow’s milk protein. 50-80% percent of babies diagnosed to a cow’s milk protein allergy will be able to tolerate soy. A breastfeeding mother, if she chooses to continue breastfeeding, will be advised to remove all the dairy and food consumed which contain cow’s milk protein. This elimination diet needs to be tried for at least 4 weeks to notice an improvement. It can be tricky to start with and a specialist dietician would be recommended to advise the mother of suitable substitutes to maintain an adequate intake of calcium and other important nutrients. There are a lot of foods that contain milk solids and hence contain cow’s milk protein. If formula feeding, the formula will be changed to either a soy, an extensively hydrolysed formula (eg.Alfaré (Nestlé) or Pepti-Junior (Nutricia)), or an amino acid based formula (EleCare (Abbott) or Neocate (SHS)). There is no place for partially hydrolysed (known as HA) formulas or other mammalian milks (such as goats milk) in treating cow’s milk protein allergy. It all depends on the age of the baby with what their pediatrician thinks is best for the particular baby they are treating. If the baby is less than 6 months, they will usually try them on an extensively hydrolysed formula and if that is not tolerated after a trial, will move on to an amino acid based formula. A lot of parents say that when they do initially try an extensively hydrolysed formula or amino acid formula that the baby won’t drink it. It is worth persisting as they do get use to it. It can be frightening for a parent thinking ‘my baby won’t drink this formula’’ but keep trying because I do hear a lot of parents say, that my child gradually got used to it.
Studies show that lifestyle modifications together with changing formula or diet will give 78% improvement of reflux scores. If all other measures have failed, and reflux symptoms are problematic or associated with complications, a trial of either a Histamine 2 receptor antagonist (eg. Zantac) or a proton pump inhibitor (PPI) (eg.Losec) medication may be prescribed. The research does show that PPI’s are superior to Histamine 2 receptor antagonists. As a pharmacist and speaking to many parents, I will often hear, ‘Thank goodness for this medication, I have a completely different baby now.’ The most common PPI given to infants is Omeprazole (Losec) made into a liquid suspension. They all work in the same way by reducing the amount of acid produced by up to 90%. Omeprazole suspensions need to be prepared by a compounding pharmacy who will also pleasantly flavour the suspension. Other brands of PPI’s include Nexium and Zoton and parents will be given instructions on how best to give the medication to their baby. They are given as a once a day dose, and will be trialled for at least one month. As your baby grows, the dose often needs to be increased not due to tolerance but between 6 and 12 months, babies metabolise the medication faster (ie their bodies break it down faster). The treatment will be reviewed regularly by your doctor and when the symptoms are well controlled, stopping treatment may be considered. A step down approach is recommended over a period of time, whether that be giving the medication every second day or lowering the dose (gradually), and then obviously assessing how the baby responds to that, but the length of treatment will vary for each child.
Please feel free to leave comments on this blog and if there are any questions I am more than happy to answer them. Also if you tried a remedy that worked well for your children that was or wasn’t mentioned above, let me know. I hope this information does help.