INDEX (Click on section to go straight to it)

         • WHAT IS INFANT REFLUX?
         • REFLUX OR COLIC?
         • SYMPTOMS
         • DIAGNOSIS
         • THE ROLE OF FOOD ALLERGIES
         • GENERAL FEEDING TIPS
         • BOTTLE-FEEDING
         • BREASTFEEDING
         • INTRODUCING SOLIDS
         • GENERAL TIPS FOR MANAGING REFLUX
         • Using Milk Thickeners
         • Other Medicines

WHAT IS INFANT REFLUX?

Reflux in infants or Gastroesophageal Reflux (GER/GOR) to give it its official title, is a very common but often distressing condition. More than 50% of infants regurgitate more than twice a day. Reflux is the involuntary and effortless regurgitation of stomach contents. There is a valve at the top of the stomach called the Lower Esophageal Sphincter (LES) that is supposed to stop food, liquid and acid from coming back up the oesophagus. In many infants the valve is immature and doesn’t function effectively resulting in posseting (bringing milk back up) and, what can be, extreme discomfort. Reflux is even more common and often more severe in babies born prematurely as their LES is so under-developed. In most babies, symptoms peak between one and four months and start to improve as baby starts to sit up more, eat solids and the LES valve and other stomach muscles strengthen. Reflux usually resolves by around 12 months but it can continue and in very rare cases require surgery and other medical interventions.

Although it’s often nothing to worry about in itself, it does need treatment as 10% of babies may go on to develop complications such as dehydration and oesophagitis (inflammation of the oesophagus).

Some infants will exhibit many of the symptoms of reflux but are not actually sick. This is called Silent Reflux and it is very common for it to be mistakenly diagnosed as colic. Silent Reflux is often more painful as the stomach contents irritate the oesophagus on the way up and on the way down. Presumably it’s like having near constant heartburn.

Where the reflux causes the baby distress in any way, it is generally called Gastroesophageal Reflux Disease (GERD/GORD).


REFLUX OR COLIC?

Although colic is believed to be a condition in its own right, it has been shown that a significant proportion of babies labelled as 'colicky' are actually suffering from Infant Reflux (usually Silent Reflux - see above) and/or related allergies or intolerances (see below).

SYMPTOMS

        • Posseting/vomiting/ regurgitating stomach contents in varying amounts
        • Disrupted sleep patterns with frequent waking
        • Erratic feeding patterns – refusing to feed or wanting to feed constantly
        • Feeding problems - Arching of neck or back, stiffening or drawing up of legs, screaming, crying whilst feeding
        • Poor weight gain (although some reflux babies won’t dip below the 90th percentile because of constant feeding)
        • Excessive crying and irritability
        • Persistent hiccups
        • Persistent hoarseness and/or coughing
        • Wheezing and/or congestion
        • Recurrent chest/ear/nose/throat infections and colds
        • Gagging and difficulty swallowing (Dysphagia)
        • Sour-smelling breath
        • Wet burps


DIAGNOSIS

In the vast majority, no tests will be necessary for your health professional to diagnose reflux. Getting a diagnosis may not always be that straight-forward. Getting useful information about how to manage the condition may be even harder. Despite the fact that reflux is such a common and treatable condition, it is still not widely recognised which is why it is often mistaken for colic. It is common to be told that there’s nothing to be done but wait till your child grows out of it but Soothe Your Baby are here to say ‘Rubbish’!


THE ROLE OF FOOD ALLERGIES

Happily, there are  many strategies that you can employ to help your baby. The first thing to consider is the role that a food allergy or intolerance may play in your baby’s reflux. Although cow milk allergy/dairy intolerance doesn’t cause your child’s reflux, it often exacerbates the condition and is a factor in up to 42% of cases, so it definitely worth investigating.

The symptoms of cow milk allergy/dairy intolerance (taken from www.actagainstallergy.co.uk) are either: gastrointestinal (e.g. vomiting, diarrhoea, abdominal cramps, bloating and gas); dermatological (e.g. skin rashes, eczema, urticaria/hives) or respiratory (e.g. oedema – water retention in hands, arms, feet, ankles and legs; wheezing; rhinoconjunctivitus – runny/itchy nose, sneezing, watery/itchy eyes etc). Gastrointestinal symptoms occur in 50% of allergic infants, 31% exhibit dermatological ones and 19% get respiratory symptoms.

If you suspect a cow milk allergy/intolerance then dairy products should be removed from your child’s diet. In the case of formula-fed infants, there are many hypoallergenic formulas based on hydrolysed proteins or amino-acid based formulas available and your doctor, health visitor or pharmacist can go through these options with you. There are soy-based formulas available too but these are not necessarily a good option as milk allergic infants are commonly allergic/intolerant to soy products as well. There is also some evidence to suggest that the plant estrogens in soy products can be detrimental to development of baby boys.

In the case of breast-fed infants with reflux, it is a little more complicated if you suspect they are intolerant or allergic to something. Although dairy intolerance/allergy is the most likely, allergens from anything you eat get into your breast milk and pass to your baby. There are allergy tests for babies but there are no reliable tests to detect an intolerance and the symptoms can be just as severe as an allergy so there are two options really. One is just to eliminate dairy products (goat and sheep too) from your diet for at least two weeks and see if there is any improvement in the reflux. This includes all traces of milk protein no matter how small. Labelling is pretty good these days and it will generally say if any ingredient is derived from milk but it’s best to check to be on the safe side. Some infants (including my own) will react to even the smallest trace of milk protein. Avoiding soy products too would be a good idea since soy intolerance often goes hand-in-hand with cow milk allergy. There a plenty of good tasting rice and oat-based milk products to choose from.

Your second option is to follow a diet that will eliminate all allergens from your breastmilk. This way you can more precisely pin down what, if any, food your baby is sensitive to. You should definitely enlist the help of a doctor or dietician to do this as it is very restrictive especially for someone who is breastfeeding. Your health professional may not feel that it is necessary to be quite so restrictive. This particular elimination diet is taken from www.askdrsears.com. The diet is based on eating the least allergenic foods in each of the food groups for two weeks. The foods are free-range turkey and lamb; baked/boiled potatoes; rice and rice-based pasta, cereals, milk etc; millet; cooked yellow/green squash and pears.

You may not see any improvement straight away and it may take a week to ten days to notice any changes. It can take up to two weeks for your breastmilk to be clear of allergens. Then after two weeks, gradually add one allergen into your diet every four days and make a note of any reactions. It is important to stick to the four day guideline as it can take this long for symptoms to develop in your infant. Start with less commonly allergenic foods such as sunflower seeds, carrots, beets, salmon, oats, grapes, avocado and peaches). Next add wheat, beef, eggs, nuts and corn. Avoid the following foods for the longest time: dairy, soy, peanut, shellfish, egg, coffee, teas, colas, caffeine, chocolate, tomatoes, citrus fruits and gas-producing vegetables (broccoli, cauliflower, cabbage, onions, green peppers etc). Spicy and acidic food can also aggravate reflux.

Alternatively you could keep a food diary and try to spot reactions to particular foods but it is a fairly hit-and-miss method for spotting allergies or intolerances as there may be time-lags involved that will make it difficult to identify the offending foods.

It is worth bearing in mind that, in the case of older babies/toddlers and children with persistent GERD, a recent study has shown that 80% show dramatic improvement on a gluten-free diet. (Many children with persistent GORD are sensitive to gluten)

As mentioned earlier, reflux isn’t caused by an allergy or intolerance, so although eliminating the offending food will may result in a dramatic improvement, it is unlikely to cure the reflux altogether as the root cause is a weak LES (stomach) valve. So it’s definitely worth employing some of the following tips for managing the condition.


GENERAL FEEDING TIPS

• Keep your baby upright at 30 degrees with their spine straight and head supported for 30-45 minutes after each feed. This sounds like a tall order but our positioning products make this very easy.
 • The position you feed your baby in is just as important - the more upright and straight their spine, the better. Most breastfeeding supports position your baby flat and can cause them to crane their necks but our Pollywog Feeding Positioner positions your baby at an angle while keeping their spine straight and avoiding pressure on their tummies. It can also be used for bottlefeeding as can the Baby AR Pillow. Feeding your baby at an angle means that gravity helps the milk to stay down and keeping baby’s spine straight ensures a smooth swallowing action and transit of milk to the stomach.
• Feed your baby in a calm environment – over-stimulation and sudden noises can aggravate reflux and colic
 • Offer smaller, more frequent feeds
 • Burp/Wind your baby gently and often, every 1-2oz for bottle-fed babies to prevent a large amount of air building up in their tummies
 • Avoid jostling, jiggling or over-stimulating your baby for 45 minutes or so after feeding


BOTTLE-FEEDING TIPS

 • Ensure the bottle is fully tilted so that the teat is completely full.
 • Experiment with bottle teats – there are a lot out there, many designed to minimise colic and reflux symptoms. Dr Brown’s teats and bottles are highly recommended by many.
 • If using thickened milk, you may need a faster flowing teat.
 • Because formula takes longer to digest, you may need to keep baby upright and calm for nearer 45 minutes after each feed to minimise refluxing episodes.


BREASTFEEDING TIPS

There are several issues to consider when breastfeeding a refluxy baby:

Overactive Letdown Reflex

If you have an overactive letdown reflex, this means that initially your milk lets down so abundantly that your baby can’t keep up with the flow. Your baby may choke or gag and pull away and can end up swallowing a large amount of air. If you suspect this is the case, have a cloth/towel nearby to release the initial rush of milk into and then latch baby back on when the flow has slowed. Alternatively you could try expressing some milk before you latch baby on to allow the flow time to slow down. It’s important not to express too much however as this will send the message to your body to produce more milk and may encourage the overactive letdown.

Foremilk/Hindmilk Imbalance

Another issue that can exacerbate reflux is a foremilk/hindmilk imbalance. Foremilk is the milk your baby gets when they first latch on that quenches their thirst and then after ten minutes or so they get hindmilk which is higher in fat and more nutrient dense and satisfies their appetite. If your baby gets too much of the former which contains more lactose, it can upset their digestive system and worsen reflux and colic. Foremilk is relatively low-calorie and quickly digested so your baby may also feed frequently. It can be down to an overabundant milk supply and releasing the initial rush of milk into a towel/cloth as above may help. It can also be due to your baby not latching on properly or swapping to your other breast before the one they’re feeding from is empty. If possible during any 2-3 hour period, only feed your baby from one breast to ensure that it is completely empty before offering the other.

As mentioned before, there are many things in your diet that could potentially aggravate your baby’s reflux. Keeping a food diary could help you identify the offending foods or you could try an elimination diet with the assistance of a doctor or dietician. Common offenders include dairy products, wheat, chocolate, acidic fruit, caffeine, alcohol, fatty foods, spicy foods, citrus fruits, eggs, onions, garlic and gassy veg. A food diary helped me to identity that my baby’s reflux was worse when I put balsamic vinegar on my salad but it took me a while to figure it out!

Try using a Pollywog Feeding Positioner to position your baby at the right height and angle.

TIPS FOR INTRODUCING SOLIDS

The jury is definitely out when it comes to the best time to introduce solids to a refluxy baby. Some health professionals will recommend trying it early at 4 months as solids are easier to keep down than milk but it’s worth bearing in mind that at this stage and beyond, milk is still baby’s primary source of nutrition - the introduction of solids is just to get them used to different textures and tastes. For some infants, introducing solids will improve their reflux but this is definitely not the case for all babies. As there is so much conflicting advice out there, it really has to be parent-lead and based on what you feel is right. The worst that can happen is that you introduce a little baby rice at four months and it doesn’t help so you delay it a bit longer.

A definite tip is to avoid giving your baby acidic drinks, acidic fruits and vegetables such as tomato-based foods, onions, oranges, mangoes etc and spicy food. Again keeping a food diary is a good idea to record any reactions your baby might have.

The main thing to remember is to take it slowly – unfortunately the introduction of solids won’t necessarily help your baby’s reflux so you may as well take your time!


GENERAL TIPS FOR MANAGING REFLUX

 • The worst position for refluxy babies is generally flat on their back or upright and slumped such as in a carseat. The consensus amongst the medical profession is that a 30 degree angle of elevation is best for babies with reflux. Generally babies with reflux will sleep considerably better if the head-end of their mattress is elevated. This is simply and safely achieved using a Tucker Sling. Whilst this will not always be possible, it is helpful to keep your baby as upright as possible without slumping for 30-45 minutes after each feed. There are many products out there that claim to help refluxy babies but many provide an insufficient angle of elevation to make any difference. We have selected and imported the best positioning products available from the US. All these products provide a good angle of elevation whilst keeping your baby’s spine straight and supporting their heads.

 • Put a pillow under the head-end of your baby’s changing mat and try to avoid changing their nappy straight after a feed where possible (not particularly easy as many babies poop during or just after feeding!).

 • Avoid tight clothing and nappies that put pressure on baby’s stomach.

 • A dummy can help refluxy babies as the extra saliva and swallowing has a neutralising effect on stomach acid.

 • Choose your carseat carefully – some carseats have deep seat wells which young babies can slip back into and end up slumping forward – this will almost certainly worsen reflux. Most carseats these days recline to various angles which is much better. Better still is that most seats now come with extra foam padding for young/small babies that pads out the well of the seat and the sides and keeps them from slumping forward or sideways. If you carseat did not come with any extra newborn padding, it is definitely worth phoning up the carseat manufacturer as many of them give this extra padding out for free. There are many carseat accessories available to buy separately but beware – many come from the States and are not tested with UK carseats. They can change the baby’s position within the carseat to the detriment of your baby’s safety. Always check with your carseat manufacturer before using these products or better still use the padding provided by the manufacturer where possible.

 • Wherever possible don’t let anyone smoke near your baby as tobacco smoke aggravates acid reflux.

Using Milk Thickeners

Thickening your baby’s milk may help them keep it down. You can buy ready-thickened formulas in most supermarkets and pharmacies or you can thicken the milk yourself using a separate milk thickener such as Carobel.

Your doctor may also prescribe an anti-reflux agent such as Gaviscon which is suitable for both breastfed and bottle-fed infants. Gaviscon is an alginate that produces a gel when it reacts with acid in the baby’s stomach, thickening the food, making it more difficult to regurgitate.


Other Medication

Infant reflux medicines typically fall into three categories: Histamine H2-receptor antagonists (H2-Blockers); Proton Pump Inhibitors (PPIs) and Prokinetic Agents. H2-Blockers reduce the amount of acid the stomach produces. Ranitidine is the most commonly prescribed H2-Blocker in this country. PPIs also reduce the amount of acid the stomach produces by a different mechanism. Prokinetic Agents keep the contents of the stomach from reaching the esophagus and reduce the amount of acid in the stomach. They make the LES (stomach) valve shut tighter and make the contents of the stomach empty faster. It is definitely worth pursuing other avenues before using medications unless your doctor or consultant believes it is absolutely necessary.