Reflux and breastfeeding

Reflux - it's a biggie. There's a good chance that in the early weeks of your baby's life you will wonder if he has reflux (perhaps starting around 3-4 weeks), or have it suggested to you. You likely know other babies who are on medication for reflux. It almost seems that reflux is queried now for any fussy feeding or unsettled behaviour, but is anyone actually looking at why that baby is unsettled? Reflux exists of course, but is it a medical problem, and do all these babies need medicated? Are large numbers of babies really producing excess acid making their reflux painful? I believe that many cases of reflux are actually indicating a feeding issue, and have non medical solutions.

Reflux is common and physiologically normal. The NICE guidance describes it as follows:

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is a common physiological event that can happen at all ages from infancy to old age and is often asymptomatic. It occurs more frequently after feeds / meals....

The passage of gastric contents - that can sometimes be air. Reflux is normal. Each time we burp, we are having reflux. Reflux is something that happens to us all frequently and is not problematic. What the word has come to mean however is something different. It has come to mean unsettled behaviour in babies. It is come to be associated not just with vomiting, or posseting, but also frequent waking, or a baby wanting to be held, or a baby who is having feeding issues. In practice Western society has started to confuse reflux with other issues and behaviours.

NICE guidance suggests that 40% of babies spit up/vomit, and for the vast majority of these babies it is a laundry issue, not a medical one. Another group of babies are often labelled as having 'silent reflux' or 'occult reflux' where the reflux doesn't make it as far as the mouth, or perhaps is re-swallowed once it gets there. Sometimes we hear swallowing or see other symptoms, but sometimes there are no signs of reflux at all, but it is diagnosed simply from behaviours like crying, back arching, pulling on and off the breast ( which is sometimes misdiagnosed as breast refusal).

A common picture is that a mum with a concern visits her GP. After a discussion around symptoms baby is often started on a milk thickener (carobel) or an Alginate (gaviscon), and so starts a medication cycle. These medications make many babies constipated and the now constipated baby has tummy pain and is more unsettled and fussy. This often becomes confused with more reflux symptoms and so the baby is moved on to the next level of medication - proton pump inhibitors which reduce stomach acid.

Can we all just take a step back? Imagine your washing machine is leaking. Each time you wash a load of clothes you see a puddle of water gathering on the floor. You call a plumber and explain about the puddle of water. Your plumber diagnoses a leak and suggests you change a valve to reduce the amount of water which fills the machine. Now when you use the machine the puddle is smaller but your clothes don't seem to be washed properly either. Is that a good solution?

You call a second plumber. This time the plumber comes to your home and observes a wash. He pulls the machine away from the wall so that he can observe the entire water cycle and notices that one of the pipes is loose. He fixes it. No more puddle. Your clothes get washed, the floor stays dry and everything works as it should because he understood what was causing the problem and removed it, rather than working on the symptoms.

Why are we not looking for the root cause of a baby's reflux? Why are we managing symptoms? Deal with the root cause and maybe we can eliminate the problem with reflux.

So what are the root causes?

It's a baby - The spitting up may be entirely normal. Babies have little core strength and many spend a lot of time either semi horizontal or horizontal. They have a liquid diet and can have an immature valve closing the top of the stomach, so that makes it leaky. It's a bit like half screwing on the top of a bottle of water and then laying it down. The water is going to leak back out of the top. This normal physiological reflux generally resolves in time as the baby begins to sit up and moves to solid food. In the mean time it may actually be beneficial. The Canadian paediatrician Jack Newman believes that spit up may be a good thing in an otherwise healthy, content baby as it coats the oesophagus twice with antibodies - once on the way down and once on the way up again. The NICE guidance is very clear that either spitting up or silent reflux in and of itself is not a problem and should not be medicated without other symptoms being present.
Too Much Milk Too Quickly - Babies are designed to drink small amounts frequently - much more frequently than we expect. A normal physiological frequency for a baby may be to have small amounts every 90 mins - however we often expect them to feed 3 hourly. A baby feeding 3 hourly needs to drink twice as much at each feed as a baby drinking every 1.5 hours. Overfilling the stomach causes it to stretch and that loosens the valve at the top of the stomach - allowing the overflow to escape. Think of this as a safety valve in this case allowing excess to escape and for the baby to feel more comfortable. Adjusting feeding so that there are appropriate amounts at a normal frequency can reduce reflux episodes.
Aerophagia - This is a medial term which just means swallowing air. A baby who is clicking, gulping, spluttering may be taking in more air than they should. A baby who has a sub optimal latch may be taking in air. Scheduling feeds and feeding on a very full breast or expressing for a freezer stash can create issues with swallowing air due to the flow being so fast which may interfere with a baby’s suck-swallow-breathe rhythm. A tongue tie or muscle tightness from birth can also impact that nice relaxed suck-swallow-breathe rhythm potentially causing swallowing of air. In my previous blog I talked in detail about why a baby may swallow air during a feed so if you missed it click here. If a lot of air is swallowed, the stomach valve opens to allow it to escape again - for the baby to burp. As the air comes back up, milk may come with it. The resolution for this is to correct feeding issue, or resolve the tongue / muscle issues so that air isn't swallowed. Without the air being swallowed the reflux can be eliminated or reduced to a manageable level. Having a good feeding assessment will help to optimise feeding and identify any issues with air intake.
Low Milk Intake - This is more usually applicable to silent reflux where the diagnosis has come from symptoms of back arching, pulling on and off the Breast (which may have been misdiagnosed as breast refusal), and poor weight gain. The poor weight gain is sometimes considered to be due to "silent reflux" causing pain, however the most common cause of poor weight gain is lack of calories so this should be investigated first. Where milk supply is low the flow of milk is slow. It is a very common behaviour for a baby to arch, pull on and off the breast and cry in frustration when flow is slow. Milk volume is a complex interaction of both mum and baby so low supply could be due to ineffective transfer from mum to baby due to birth interventions, something anatomical, poor latch, or baby not being at the breast enough. Resolution would be to increase supply in mum and ensure baby is transferring effectively. A good breastfeeding assessment and support can help to get things back on track.
Allergies/intolerances - This is a more complex picture. When reflux occurs in healthy babies it is generally painless. Babies are on a milk diet (which neutralises acid), and the oesophagus has a number of defence mechanisms against acidity, so generally babies who are spitting up are pretty comfortable, or only mildly upset by refluxing. A minority of babies however, do become very distressed when refluxing. Where pain is involved there is often another underlying. Allergies can cause inflammation within the body, and where reflux is touching already inflamed tissue, there may be pain where a non-allergic baby would experience none. For these babies, identifying and removing the allergen allows the inflammation to resolve and for the reflux to become normal physiologic, pain-free reflux again.
It’s important to say that allergy has multiple symptoms - reflux alone is not diagnostic of allergy. Allergy affects multiple systems in the body - the GI system, the skin, the respiratory system, so there are usually multiple indicators of an allergy present. My blog on allergy and symptoms is here. Again, a good feeding assessment should pick these up and hep you to figure out if an allergy may be an issue for your baby.
Gut microbiome - Our gut bacteria is a huge topic of research at the minute. We have as many bacterial cells in our bodies than human cells and a healthy microbiome is necessary for digestion and for immune function, among other things. A healthy microbiome should allow for easy digestion, and the production of gas that is reasonably comfortable and easy to pass. A microbiome which has more pathogenic species however may cause issues with digestion. It may produce more of the methane and sulphur gases causing bloating and pain. It may cause constipation and straining. That constipation and straining in return can cause reflux due to the abdominal pressure. A feeding assessment should look at gut function and any undiagnosed constipation as well.
Baby's habitat - A baby is extremely immature at birth, with a nervous system reliant on mum's body. If a baby is not in contact with mum, digestion does not work optimally. We have been primed to believe that we need to set a baby down after feeding, not to spoil our babies, or create rods for our backs. When a baby is separated from mum however the baby can become distressed, and emotional stress can lead to vomiting. This may explain why baby wearing / carrying baby also seems to help with reflux.

Usually babies are not bothered by reflux, but they do receive emotional regulation from their mum. If a parent is worried, and stressed about their baby, then a worried and stressed nervous system is regulating the baby. This leads to a more anxious baby and that can lead to more fussy behaviour and even more reflux. A good breastfeeding assessment should involve counselling about what is normal, and concentrating on the parent's worries and fears just as much as the baby's feeding.

NICE guidance is very clear on where normal reflux becomes something which needs investigation.

in well infants, effortless regurgitation of feeds... does not usually need further investigation or treatment

For silent reflux it states the following:

Do not routinely investigate or treat for GOR if an infant or child
without overt regurgitation presents with only 1 of the following:
unexplaied feeding difficulties (for example, refusing to feed, gagging or choking)
distressed behaviour
faltering growth
chronic cough
hoarseness
a single episode of pneumonia

If a baby meets the criteria for further investigated, the guidelines are also clear about what should happen next:

In breast-fed infants with frequent regurgitation associated with marked distress, ensure that a person with appropriate expertise and training carries out a breastfeeding assessment.

Is this happening? If your baby was diagnosed with reflux were you first referred to a person with appropriate training to carry out a breastfeeding assessment?

What's wrong with the medications?

Most mums don't feel comfortable with the idea of medicating their tiny baby, and side effects of the drugs are often not discussed in depth. Thickeners often have a side effect of thickening stools or causing constipation. Proton Pump Inhibitors (such as Losec) or H2 blockers (such as ranitidine) reduce stomach acid. These do not stop the reflux (in fact vomiting is listed as a side effect). Reducing acid may initially seem like a good idea, but we have stomach acid for a very good reason. Our bodies need an acid environment in order to digest proteins, and it also acts as an immune defence against pathogenic bacteria which are destroyed in an acidic stomach environment. Without adequate stomach acid babies are more at risk of infection, of developing allergies, even of bone fractures. In some cases treatment can even suppress appetite In cases where the issue is low milk intake the drug may seem to help for a while, but the supressed appetite can mean that baby drinks even less milk, and weight gain falters. Acid levels also affects absorption of vitamins and minerals in the gut. With these side effects, and the clear guidelines from NICE, doesn't it make sense to investigate fully before considering drugs?

There is no doubt that some babies do have GORD. These are very unhappy babies, and they need our help. They may indeed need medication, but they also need help with breastfeeding. Those babies are in the minority though. Most babies probably don't need medication, but they absolutely do need good breastfeeding support. A thorough feeding assessment should involve observing a feed, optimising latch, and looking at a complete history of feeding so far. It should consider baby's ability to transfer milk, weight gain and pattern of feeding through the day, any extra expression that happens regularly, how birth went and if there could be subtle effects, mum's feelings around feeding, any pain or discomfort, concerns or fears etc. It should consider parent and baby as a unit and is much more than treating a stomach. A feeding counsellor or lactation consultant should also know when reflux is more than a feeding issue and does need medical help.

Reflux is distressing - for the whole family, and our babies deserve to have someone take the time to investigate and treat the cause, not just symptoms.

For every effect there is a root cause. Find and address the root cause rather than try to fix the effect, as there is no end to the latter. - Celestine Chua

See Part 2 on the Importance of Stomach Acid

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Reflux and breastfeeding

So what are the root causes?

What's wrong with the medications?

Further Reading