Sunday, August 22, 2010

Babies with Reflux?

There are so many babies diagnosed with reflux lately... I have been thinking off and on about why this may be. We know that formula-fed infants are more likely to have reflux than breastfed infants, but we still hear of so many breastfed infants with reflux as well. Apparently reflux was not common in babies 20 or more years ago, as my mother has commented, "What is up with all these babies with reflux now?" She just didn't know of any babies having reflux when she was raising babies throughout the 1980s.

So, one thought that immediately came to mind: The Back to Sleep campaign (which I believe was introduced around 1990, but don't quote me on that). Medical professionals used to advise parents to place their babies on the bellies to sleep, but research has shown that position to be associated with a much higher risk of SIDS. So it is now advised that babies are placed on their backs to sleep. Lying on the back is a position in which reflux is more likely to be irritating to the throat, since the saliva can pool at the back of the throat easily that way.

Now, the Back to Sleep campaign is not a bad thing in and of itself. If parents are going to be putting their infants to sleep in separate rooms by themselves, then it is safest for them to be on their backs - they are less likely to have a stop-breathing episode while on their backs.

Babies also spend a large amount of time on their backs at other times, not just overnight and at naps. Baby swings, strollers, and infant car seats also keep them in this position more often. Sometimes babies spend so much time on their backs that the backs of their heads get so flat that they must be fitted for a special helmet to help their head regain its proper shape. Surely this is not natural, right? But it is not surprising if a baby spends 10 hours on its back overnight, a few hours each day napping in that position, and then more time on its back in swings, infant seats, and strollers. The "bucket" infant car seat is something else that is a relatively new invention. In the days when my parents were raising babies, the car seat stayed in the car. The child was always removed from the seat to go in and out of buildings. Now, it is relatively easy to keep an infant in a carseat for large chunks of time each day. So, babies are spending more of both their days and nights on their backs now than they were in the 80s and earlier.

To counteract this flat-head syndrome, the "experts" began recommending something that is referred to as "tummy time." This is intentionally placing the baby on its tummy while awake, to encourage the lifting of the head and pushing up with the arms, and also getting the back of the head off a surface.

In addition to the time spent on their backs, babies have other things which might be exacerbating the reflux nowadays. Scheduled feeding is one thing that comes to mind. With a breastfed baby, the initial milk is thinner and gradually gets thicker and more filling as the feeding progresses. Thus, the longer a mother goes between nursings, the more foremilk there is at the next feeding. The fattier hindmilk is what the baby receives further into a feeding. Cutting off a feeding too soon may cause a baby to miss most of the hindmilk, and spacing his feedings out to once every three or four hours gives the mother's body more time to build the foremilk back up. Frequent removal of milk causes the baby to continue to get more hindmilk at each feeding. Getting too much watery foremilk and not enough of the thicker hindmilk could contribute to reflux symptoms. Sometimes doctors recommend that mothers thicken their milk by pumping it and adding rice cereal - but introducing solid foods (of which rice cereal is one) prior to about 6 months increases the baby's risk for allergies. Rice cereal is also likely to cause constipation in babies, so even if it seems to help with the reflux, it may cause other problems. Nursing the baby more frequently could aid in this. In thinking of nursing as more than just a set feeding time, mothering through breastfeeding leads to nursing for comfort and thus being done more frequently.

Mothering through breastfeeding also tends to include close contact with the mother, which includes the infant being carried around both while awake and while napping. An upright position in a sling might be helpful in reducing reflux. Neither of my children really liked to lay down in the sling unless they were nursing, but the upright tummy-to-tummy position was great for them.

Babies who co-sleep with their nursing mothers end up spending time on their sides at night as they nurse. Also, the mother may switch them from side to side during the night. Therefore, less time is spent on their backs even while they are sleeping overnight.

One last thought is that a bottlefed baby is being fed on his back in a reclined position, whereas the breastfed baby is more on his side, and in the natural position has his legs and belly lower than his head.

So, in looking at all this, it appears that it may be that our straying from the biological norms of infant care contributes to a higher incidence of reflux. Rather than introducing other solutions, perhaps we could go back to the root of the issue and make changes there? I am not saying that this is definitely why babies have reflux more often lately... I am sure there are co-sleeping babies who never spend time on their backs and are carried upright and still seem to have some reflux symptoms. But I haven't heard any speculation on why it is that so many babies are diagnosed with reflux lately, so I thought I would do a little speculating myself. Any other ideas to add? Has anyone read anything which discusses potential reasons for this infant reflux epidemic?


Kate said...

both of my babies had reflux, to the point that they required visiting GI doctors, etc due to poor weight gain. but i think for both of mine, it was related to food allergies (both had dairy/soy intolerance). you know i exclusively breastfed both, delayed solids, wore them in slings a lot, nursed on demand, co-slept, etc etc... so there is definitely something else going on. i think the dairy intolerance probably has something to do with it... so many formula babies end up on specialized formulas, that i've met at least. so i wonder if it is the highly processed dairy milk we've been drinking for a few decades... babies can't tolerate it as well (they were most likely exposed to it in utero). they don't digest it as well, therefore it causes reflux in the little ones. this is entirely speculation... i've never done any research on it or anything. i just know for mine, giving up all dairy (even all processed foods to avoid hidden dairy) and then all soy was the magical solution. they gained weight better and seemed more content in general.

Karen said...

I don't know that there is a correlation between formula fed babies and reflux. I actually think it's a genetic issue that is aggravated by the back to sleep campaign. Both of my daughters were breastfed and they both suffered from reflux. The fact that they had/have reflux is no small surprise considering that both their parents and all four grandparents have reflux as well. I think it's a condition that just wasn't diagnosed much in infants twenty or thirty years ago. Nine years ago I was told it was a "laundry issue" and I had to insist that the doctor give my daughter medication to alleviate her pain. The poor kid screamed for hours a day and nursed roughly every 30-60 minutes a day for the first four months unless she was sleeping. Life for her was a cycle of scream, eat, spit-up, scream, spit-up, eat. With my second daughter we recognized the reflux much sooner and had her on medication by 4 weeks old. That coupled with tossing out the "back to sleep" mentality made for a much happier baby.

When it comes to reflux babies, I've often wondered if the mothers noticed that their baby had unusual (read: almost constant) amounts of hiccuping before they were born. Both of my children hiccuped for several hours a day for the last trimester.

Erin said...

Yes, very good point... it appears that dairy is the most common allergy-causing food. I know of people who say they tolerate raw cow's milk better, so it may be the processing. Thanks for bringing that up. Perhaps the things in the foods we eat is part of the issue too.

Erin said...

I wonder then if genetics playing a role went unnoticed in many babies back when they slept mostly on their sides next to their mothers and then when they slept on their tummies. Back to Sleep just made it more obvious earlier in life, perhaps.

I don't want anyone to think i'm advocating for ignoring Back to Sleep... for a baby under 6 months sleeping alone, it is safest. I think this all adds evidence to the idea that biologically, young babies were not intended to be left sleeping alone for long.

Tiny Actions said...

I wonder if there's more a diagnoses of reflux when in fact there's more an undiagnosed dairy sensitivity. (As you know I lived through this with two of my kiddos). This can occur in either formula fed babies or breastfed babies. Either way, anyone who suspects reflux should investigate a dairy allergy as well.

Tiny Actions said...

The other thought I had was that a baby's digestive tract is not fully devolped until the age of 3 months. Giving rice laddened breastmilk or formula can make their tummy seem full is probably not good for tiny still developing tummies either.

Kris said...

All of mine were mothered, breastfed and co-slept. None had reflux. I agree, this is a great point.

Tiny Actions said...

Okay, you really have me thinking about this...One other reason for the increase in reflux diagnoses could also be the pediatricians lack of knowledge on probiotics and digestive enzymes. They do make both for young infants and have worked wonders on my kiddos when needed. I'm done clogging your comments box :)

Erin said...

Don't worry about too many comments, Sue... I think that way myself and am always adding something a few minutes later!

Very interesting about the dairy sensitivities/allergies being misdiagnosed as reflux... the infant's gut is not fully "closed" until about six months, meaning the dairy proteins are more likely to irritate them because they can't block them from entering the gut, so if babies are allergic, then it causes inflammation when those dairy proteins get into the gut. The breastmilk actually helps to create a protective lining in the gut, so even if a baby is allergic to dairy and the mother is consuming it, at least he has the benefit of having a gut that has the correct bacterial environment, even though he may be having reflux symptoms or other allergic symptoms.

So, forming a hypothesis here:
The higher incidence of babies being diagnosed with reflux may be influenced by various cultural norms such as Back to Sleep, lack of co-sleeping, and other practices which involve the infant being on its back frequently, but may also be complicated by dairy sensitivities/allergies or other predispositions to reflux symptoms such as genetics.

Kate and Sue, I am curious if the doctors first said that your kids had reflux and then prescribed meds before discovering that it was really dairy sensitivities... do doctors tend to say "it's reflux" before considering allergies? And the baby may truly be having reflux, but caused by the dairy (and/or other food sensitivities)... I do think that often times, doctors diagnose the symptoms ("it's reflux, take this med") rather than finding the root cause (dairy allergies in some cases). It is also important that, as Kate mentioned, a sensitivity might require complete elimination of the offending food, meaning for dairy that you check all labels for casein and whey and lact-anything. I know that lots of times doctors will just say "eliminate dairy" when an allergy is suspected, but then a nursing mother might only avoid milk, cheese, and ice cream and not think about reading the labels on the bread, cereal, and granola bar packages. Also, they may only eliminate them for a few days or a week, when you need to give it a full three weeks with no dairy to really see if it could be the problem. People also say, "Well, I put him on a dairy-free formula, and that didn't help, so it's not a dairy allergy." But again, there can be trace dairy in formulas that are not cow's milk based, and something like half the babies who are allergic to dairy are also allergic to soy, so a soy formula may be just as much of a problem. And I had a pediatric GI doctor tell me that i could just use margarine when eliminating dairy and soy... which isn't true if you read the margarine labels!

Kate said...

with matt, it was a process to get him diagnosed. thankfully had a ped who listened to me and trusted my instinct. i said "something is wrong" and she said let's investigate. he had an u/s done to rule out physical anomalies and then a barium swallow to see how the stomach was moving, then we finally ended up seeing a ped GI doc. he took one look at him spitting up and said, yes he has reflux. then asked if i breastfed and i said yes. and he asked if i was committed to it, and i said yes. then he said, well here is what you have to do and described the dairy elimination diet.

so for this doctor, he immediately saw dairy as the potential culprit for the reflux. i think the barium swallow showed some signs of spasms in the stomach which were related to food intolerance. he did prescribe some meds, but honestly they weren't very effective and we stopped them after a few weeks (b/c the diet fixed the issue better).

second time around with emmie, i saw the signs on my own and took her to the ped there in rome. i said she has a dairy/soy intolerance. she referred me to the GI doc there. he said i was doing everything right. she did get reflux meds too, and with her they did actually help. diet alone didn't fix all of her discomfort. he advised instead of eliminating more from my diet, to soothe her with some meds for a couple of months while her GI tract matured a little more. and it worked.

so i think at least the specialist do see a relationship between dairy and reflux. but i also think society as a whole is into quick fixes and sees meds as one, instead of the month long process of removing dairy proteins from the diet. and i'm not sure how many of these reflux babies actually see anyone other than their family pediatrician. i was fortunate to have a dad who specializes in GI pathology and therefore knows the world well (at least here in SC) and directed us to where he though we would be taken care of.

so on your theory, i would say maybe reflux is common b/c of the immature GI tracts, but 50 years ago when babies were breastfed and held it wasn't noticeable OR didn't actually arise due to the child care techniques. and now with processed dairy (less tolerable), formula, and lots of back time, we see a surge in the cases?

Tiny Actions said...

Both my kiddos were never diagnosed with a reflux. My first never even spit up. She simply was irratable all the time. Then when she hit 9 months she slowed dramatically in her growth. By the time she was 13 months, she had hives all over her body. At 15 months she was diagnosed with a severe milk protien allergy. I often wonder if in the earlier months she had what's called silent gerd (basically reflux that does not show outward symptoms such as spitting up).

My son did show signs of spitting up and irrability. I knew immediately what I needed to cut out of my diet to help him. So, he never had such terrible symptoms.

And Erin, you are totally correct in saying that even though the breastmilk still contains some amount of milk protien or lactose when mama eliminates dairy, breastmilk still has other beneficial properties that in the long run do help the baby. Once my first was officially taken off dairy and myself as well, she still nursed and had no reaction the the breastmilk. My two kids with the milk protein allergies did eventually grow out of it by the time they were 4 and 2.

Erin said...

I think that after about 3 weeks of eliminating all dairy (including trace amounts in processed foods), all the milk protein should be gone from the mother's milk... but during that time, it is still best to nurse the baby. I have heard some people suggest to take the baby off breastmilk for a week (or two or three) and put them on some special kind of formula (not likely to help if it is soy-based) while the mother is getting the dairy out of her own system. Even if the baby is truly allergic, it is better to keep nursing them while eliminating dairy because of the immune factors, keeping up milk supply, preventing nipple confusion, and, particularly, keeping foreign foods out of the baby's open gut. Once formula enters, it changes the entire composition of the gut and takes awhile to go back to normal once nursing is resumed. Some people suggest that formula is better than breastmilk with traces of dairy in it for an allergic baby, unfortunately. Optimally, a mother will eliminate all dairy and continue to breastfeed if that is truly the problem. And that is so hard to do, especially if you really like milk and cheese and such, but what a great gift to give your baby, because limiting his exposure to it in the early months and years can help him outgrow the sensitivity - not always, but sometimes, like it appears to have helped with Sue's kids outgrowing it.

Kate, did your kids outgrow their dairy sensitivities, out of curiosity? There is a mom I know whose son is allergic to several things - dairy, soy, wheat, eggs... and she has nursed him for over 3 years while avoiding those foods most of the time. Some of his allergies have lessened... Some kids may never grow out of it completely... sometimes allergies appear to be genetic and last for life, unfortunately.

Kate said...

i was told by every doctor to keep breastfeeding. b/c the benefits of the breast milk on the digestive tract far out weighed any irritation caused by allergens that might be in it. when i gave up dairy with matt, after just 4 days he was much better... took several weeks for all symptoms to subside (eczema, excessive spitting up, etc).

erin, as far as outgrowing, emmie can eat anything without issue. matt has to limit his dairy intake... he can eat trace dairy in foods, and cheese and yogurts w/out issues. however if he drinks cow milk daily he will get diarrhea and his eczema flares (same with ice cream). so he drinks rice milk instead, which he prefers b/c it is what he has always drank.

sara said...

Just wanted to throw my 2 cents into the convo! Neither of my peds has been quick to prescribe anything. Ped #1 just flat-out refused; Ped #2 scheduled an u/s to rule out pyloric stenosis and also got us in with the GI doc. He did try John on Zantac, but when it seemed to make things worse, he didn't recommend trying anything else. And all peds and the GI doc were extremely encouraging to continue nursing --no one even suggested the possibility of trying formula. So some docs may try to jump the gun, but it looks like fortunately, that hasn't been the experience of anyone here. Yay for good peds! However, we're trying the elimination diet again, b/c my baby is miserable again after doing better for awhile... we're not sure what happened. :-(

Erin said...

Sorry to hear that John is uncomfortable again... eliminating dairy would be the thing to try then, and see if it makes a difference. Even though it stinks to have to avoid it constantly, a more comfortable baby is often worth the challenge! That is weird that he was doing better and then got worse again... poor baby. Give him a kiss from us!

And that is great that nobody here was told to try formula... maybe the tide is turning. When Caroline had GI issues, our ped's first response was, "she might need a special formula." I said that I really didn't want to do that, and she didn't mention it again after that. I thought it was weird of her to even say, because she is generally not a "here's a quick answer for you" kind of doctor...