#reflux #GERD
What is reflux?
Many parents are worried about reflux in their babies. This is nothing but the milk regurgitating up from the stomach into the food-pipe. Most babies spit-up or posset quite frequently after feeds. This is quite normal, and is especially seen after the first week when the mother’s milk output has increased but the stomach capacity is still expanding to cope up with this increased volume.
You can review the diagram above which shows the food pipe leading to the stomach. There is a thickened portion of muscle at the lower end of the food pipe, called a sphincter (barrier), which functions as a valve to prevent the milk flowing back from the stomach into the food pipe. Newborn babies and young infants are particularly prone to this, because of their short food pipe with poorly developed sphincter as well as supine (lying on the back) position. In some babies, the gastroesophageal junction sphincter is relatively lax. In such cases, and especially if there is over feeding, the stomach contents can easily come up. Because the babies are lying flat most of the time, the milk may come up easily into the food-pipe.
What are the effects of reflux on the infant?
There are two effects related to the reflux-one is the vomiting or the regurgitation that we see and the second part is irritation of the lower food pipe by the stomach acid. Once the milk enters the stomach, it mixes with the acid, part of the digestive juices secreted by the stomach. The stomach has a specialized lining that protects it from acid damage. However, the food pipe lacks this (as in normal conditions, it is not expected to face any acid content). When reflux persists, the milk along with the acid irritates the lower end of the food pipe. This may cause irritation or pain for the baby and explains why babies with significant reflux cry persistently with pain (unlike colic, where they have episodic crying). This irritation and changes in the food pipe are called reflux esophagitis. Once this develops, babies are afraid to feed, as swallowing when the milk passes quickly through this inflamed part of the food pipe triggers acute pain. This is when the babies start showing aversion to feeding. You might recall some parents commenting that the baby refuses to feed when awake, but is able to feed while asleep-this is because the threshold for pain (and the psychological aversion) are altered during sleep. Once the aversion sets in, it may take a few days after the condition improves for the baby actually to return to the normal feeding pattern. The longer the insult lasts, the longer it takes to overcome this aversion.
What is the best approach to manage reflux?
In majority of the cases, the reflux that happens is physiologic which means it will resolve on its own-it doesn’t need treatment but measures like reducing over feeding and slight head and elevation will help.
I am aware many parents might be reading this blog-please note the following is aimed at updating physician colleagues as well, so please don’t start any medications on your own, without discussing it with your physician, feel free to share this with them if you feel that would help.
One of the things that help is to avoid overfeeding. It is very important to get the cues right and not to push the baby to complete the feed volume. Overfeeding can happen even with breastfeeding (I will share the video link below). It is very important to educate the parents right from the start regarding the feeding pattern, so we can prevent reflux from happening. In the first 7-10 days, we expect the baby to feed almost every 2 hours-this is because the milk production is increasing, the baby has a small stomach and the volume is gradually increasing. This frequent feeding pattern helps to empty the breasts and encourages the establishment of lactation. After the milk output has increased (we can make this out by the improving urine output, satiety, sleep pattern as well as weight gain during clinic reviews), the mother can be advised to relax about the cue interpretation. Most experienced mothers start spacing feeds reasonably well at this time, and breastfed babies can go 2-5 hours between feeds. Educate the mother that the longer the gap between feeds (with an upper limit of 5-6 hours), the better it is in colic, reflux, and stool frequency/nappy rash. Unless we try to space, babies keep persisting with the pattern they are used to, and since the milk output has increased, they get excessive milk at a high frequency. This impacts their ability to digest the lactose load as well (as this is gradually increasing in the babies, and a rapid load will mean they exceed their ability to digest the lactose)-this leads to the physiologic lactose intolerance that we referred to earlier (will link the write-up on lactose intolerance). The babies have an active gastrocolic reflex, and the more often they feed, the more often they pass stools. Combining this with physiologic lactose intolerance, you have a higher risk of diaper or nappy rash as well. Colic tends to be more related to this and because they feed before the stomach is emptied, reflux occurs as well. As you can see, these patterns are all linked. And it is important to start the education early, so the mother watches for signs of improving output and avoids entering this cycle.
What are the treatment options for reflux?
In the babies with physiologic (mild) reflux, educating the parents to try and maintain the feeding pattern, avoiding overfeeding and keeping the head end inclined 20-30 degrees elevated should be adequate. Spacing the feeds helps the babies self-regulate their feed volume better, and automatically cuts down on the overfeeding as well. It also reduces engorgement or milk overflow in the mother (due to excess stimulation from frequent feeding, once lactation is established). The positioning of the baby is important too. Parents could look at options like a wedge placed under the baby’s mattress, or if using a baby basket, keep a wedge under the head end of the basket. A car seat or bouncer chair can be used (baby should be strapped in), during the day when the mother is awake and doesn’t leave the baby in for too long, but this is not recommended at night.
In babies in the NICU, we could prefer a 2 hourly frequency of feeds in the smaller babies (and those on respiratory support), so there is less volume of milk at the same time in the stomach possibly reducing the risk of reflux. We also keep the head end of the incubator or cot elevated as described above.
If the reflux has caused esophagitis, which means there is inflammation due to the acid reflux and the baby is always irritable, we may need a short course of treatment to tide over this concern. The medications for reflux include coating agents like infant Gaviscon which makes the milk a little thicker. The other options include feed thickeners (like in AR milk), which is difficult to practice with breastfed babies, and proton pump inhibitors which are antacid preparations. It’s very important not to overuse medications like the antacid preparations that suppress the gastric protection mechanism, so it’s very important to use them for a very short time under physician advice.
If the baby is on breastfeeds exclusively, please don’t introduce any formula milk. Encourage the mother to space feeds (expressing and topping up after the breastfeed could help achieve better spacing, and supervised use of pacifier could help space feeds as well). If the baby is on partial (mixed feeds with breast and formula milk) or full formula feeds, if the reflux is significant, a trial on anti-reflux milks or AR infant formula could be considered. These are specialized formula which have corn starch or bean gum (carob bean) added to the formulation. These thicken once the milk comes in contact with the stomach acid. However, we need to be aware that these formulae could thicken if we prepare in water over 70 degrees celsius (as is advised for regular formula)-do follow instructions on tin. These are relatively thicker and the teat might need to be bigger than the regular one for the baby.
Is there any role for proton pump inhibitors (PPI) like esomeprazole (Nexium) in treating reflux in infants? There is absolutely no role in preterm infants in the NICU. If we consider using it for acute GI bleed related to stress ulceration in this group, use for a minimal period of 2-3 days, only if clear it is gastritis-this is because these medications (PPI inhibition) has been shown to increase risk of sepsis and NEC (Ranitidine and other H2 blockers have been removed from the market, and should not be used in preterm babies).
In term babies with severe reflux, and persisting crying related to reflux esophagitis, there is a role to use Nexium or similar for 3-5 days only. Even in term babies, the removal of the protective effects of acid in the stomach could increase the risk of infections, and even in the term babies, there is no role (based on my practice) for a longer course as suggested in some guidelines (for a 2-week period-which in my view is fairly prolonged)-remember Nexium or similar medications don’t remove the stimulus for reflux-changes in feeding pattern with appropriate spacing and avoiding forced feeds/overfeeding are the key aspects that could help, in addition to positioning (20-30 degree head end elevation) as described above are the mainstay. The use of this medication is purely to suppress the acid adequately to improve the esophagitis (and the related pain) till the other measures take effect. And the majority of babies with reflux improve without using this, so please inform the parents to try other measures and only start if concerns don’t improve. Gaviscon has a role (infant Gaviscon sachets) but has been out of the market in UAE at least, for a while now. While it was available, I suggested using it with every feed as a trial before considering PPI use. It could be used even in breastfed babies if needed, by administering the sachet mixed in water or EBM before the feed.
Educate the family on the importance of feeding patterns and to strictly avoid overfeeding, as in most cases, that is the cause of the reflux. If the milk aversion (described earlier) has established, the parents could face a stressful period, and it is important to stress on patience and reassure parents about a relatively stable weight gain pattern. Try to remove the focus from the actual volume consumed in each feed in such cases, as force feeding will certainly worsen the problem and make it more difficult to recover from. In the most severe cases, input from an experienced speech therapist could help.
In some cases, milk protein allergy could play a role and has to be kept in mind if symptoms improve but recur immediately despite other measures or persist. Other features like blood spotting in the stools or mucus in stools could be associated, but not in all cases. Consider involving a pediatric gastroenterologist at this stage.