Reflux information

Before we define GERD, we must define "plain" gastroesophageal reflux (GER, commonly called "reflux"). This is nothing more than "spitting up": it happens when the baby regurgitates stomach contents, effortlessly, without retching.

 

Gastroesophageal reflux disease (GERD) refers to chronic GER with persistent and significant symptoms. Whereas GER is normal and not harmful, GERD is a pathological process. It occurs when the sphincter muscle at the top of the stomach (the lower esophageal sphincter) relaxes too much and fails to keep what goes into the stomach in the stomach.

 

Symptoms: Signs and symptoms of GER can vary widely. Some babies with GER may be contented -- they just spit up regularly. This is what's called a "laundry problem" rather than a health problem. These babies put on weight as expected, and no treatment or change in routine is needed.

 

In some babies, GER can be chronic and cause significant problems; in this case it is considered GERD. These babies may show:

 

·         Failure to thrive, or low intake

·         Fussiness at the breast

·         Irritability

·         Arching the back during feeding

·         Refusal to feed

·         Painful swallowing

·         Difficulty sleeping

·         Chronic cough

·         Stridor (high-pitched "musical" breathing sounds)

·         Spitting up blood (a sign of damage to the esophagus from the stomach acids)

·          

GERD tends to improve with age: 85% of babies with GERD have no symptoms by the time they are a year old. The rest may continue to have problems throughout life (Riordan, 2005).

 

Contributing factors: Several factors contribute to the development or severity of GERD:

 

·         Cow's milk allergy. About half of babies with GERD also have a cow's milk allergy (Salvatore, 2002) which may exacerbate or cause the reflux.

·         Exposure to tobacco smoke (Alaswad, 1996)

·         Use of antenatal steroids such as betamethasone and dexamethasone (Chin, 2003)

·         Use of nasogastric tubes for feeding pre-term infants (Peter, 2002)

Coexisting conditions: GERD is common in children with heart failure, cerebral palsy, other gastrointestinal tract anomalies such as gastroschisis and tracheoesophageal fistula, tracheomalacia, and in preterm babies.

 

Complications: GERD can contribute to pneumonia, asthma, apnea, and bradycardia (slow heart rate).

A baby who is fussy or refusing to feed may not feed regularly enough to maintain the mother's milk supply and get sufficient nutrition. The mother may also feel frustrated that her baby resists feeding and even arches away from the breast because of pain.

Some mothers may be concerned that their breastmilk is the cause of the reflux. Although if cow's milk allergy is contributing to the problem, she may need to eliminate dairy products from her diet, overall her breastmilk is actually protective against reflux. There is no need to interrupt breastfeeding while investigating or treating reflux.

Feed with the baby upright: Positions such as straddling or an upright football hold (or any position elevated 45-60°) can be helpful in allowing gravity to keep milk in the stomach long enough for it to be digested and to avoid putting any pressure on the abdomen which can push stomach contents upward. Keep the baby upright after feeding as well.

 

Stay on one breast per feeding: This ensures the baby gets plenty of higher-calorie hindmilk with less volume of milk overall, which can help him to get sufficient nutrition without straining his stomach capacity.

 

Feed more frequently: Lower volume feeds, fed more frequently, can help the baby digest more quickly without undue strain on his stomach (Orenstein, 1999). However, if feedings are offered very frequently, it may be necessary to continue feeding from the same breast for every feed within a period of 2-4 hours to prevent the baby getting too much foremilk which can cause digestive problems in itself, due to the high lactose load.

 

Inclined sleeping position: A baby may sleep better when his head is slightly raised, so raise his bed to a 30-45° angle. Sleeping on a parent's chest, as in kangaroo care, will also position the baby more comfortably.

 

Avoid carseats or other baby seats after feeding: These seats curl the baby inward slightly, putting pressure on his stomach which can trigger reflux. A front carrier may be helpful instead.

 

Avoid using cereal to thicken feeds: This is commonly advised but does not help (Bailey, 1987).

 

Prone position: Babies with reflux may be happiest when prone (on the stomach), and this may be acceptable when the baby is awake during the day, or possibly when the baby is napping during the day and can be observed, but a prone position is not advisable for sleeping generally as it is associated with an increased risk of Sudden Infant Death Syndrome (SIDS, or cot death).

 

Left-lateral position: Lying on the left side reduces reflux (Tobin, 1997; Ewer, 1999).

 

Fortifiers: If the baby is clearly not getting sufficient calories even after having tried all other methods to improve symptoms and improve feeding success, a fortifier containing extra calories and nutrients can be added to the mother's expressed milk and fed to the baby.

 

Investigate cow's milk allergy: As about half of babies with GERD have cow's milk allergy, taking steps to reduce or eliminate exposure to cow's milk protein (in the baby's diet, or in the mother's diet if the baby is exclusively breastfeeding) may help.

 

Medication: Medications may be prescribed to reduce the acidity of the stomach contents (such as ranitidine [Zantac]) or increase gastric motility (to speed up digestion -- medications such as metoclopramide [Reglan] or domperidone [Motilium]).

 

Monitor weight gain: If there is concern over the baby's weight gain or development, the parents may want to consult regularly with their doctor to monitor the baby's progress.