About Reflux

This section discusses the following about Acid Reflux, GER (Gastroesophageal Reflux), or GERD (Gastroesophageal Reflux Disease) otherwise known as reflux primarily pertaining to infants:

• What Is Reflux?
• Symptoms
• Diagnosis
• Treatment
• End Note
• Works Cited

What Is Reflux?
According to Children’s Digestive Health and Nutrition Foundation, (CDHNF) “Gastroesophageal Reflux occurs when an infant’s muscular sphincter-- where the esophagus enters the stomach-- allows acidic, gastric (stomach) fluids to reflux, or flow backwards up into the esophagus and sometimes reach as high as the mouth or nose” (CDHNF, "Coping"). All babies initially have some form of reflux as it "is a normal part of maturation and development that gets better during the first year of life" (CDHNF, "Coping").

Most babies will spit up and they won't be bothered by it but some babies have reflux that causes pain that adults would refer to as heartburn. In addition, if “reflux causes troublesome symptoms or complications such as failure to gain weight, bleeding, respiratory problems or esophagitis" it is referred to as gastroesphageal reflux disease (GERD) (CDHNF, "Pediatric").

The following are some facts about reflux and GERD:

1. "The majority of infants do not experience problems from reflux^"1


2. "More than 50% of babies spit up regularly in the first months of life"¹


3. "Reflux usually peaks at 4 months and stops by 12 – 18 months"¹


4. "Spitting up crosses the line into GERD when the infant begins to show symptoms including refusal to feed, poor weight gain, breathing problems and others."¹


5. "[R]eflux (GER) and cow milk allergy (CMA) occur frequently in infants younger than 1 year....up to half of cases of GER in infants...may be an association with CMA....[and] also CMA induced."³


6. Reflux is "[o]ne of the most common hidden medical causes of nightwaking (and colicky behavior)...."⁴


7. "In many cases GERD in kids can be managed with lifestyle changes, and without medication"¹


8. "GERD often runs in families"¹


9. "Kids with GERD may have frequent complaints of abdominal pain or a tummy ache"¹


10. "Children and teens with asthma are more likely to have GERD"²

¹CDHNF, "Quick Facts about Reflux and GERD"
²CDHNF, "Pediatric"
³Salvatore
⁴Sears, "31 Ways"

Early on I thought my son was suffering from reflux although he was a very happy baby, slept great, and was gaining weight well so we didn't pursue the spitting up issue until my son was around 4 months old and then he no longer wanted to breastfeed or drink his bottle. Then at 6 months he happily ate his baby food for a couple weeks and then would clamp his mouth shut and turn his head away. Once we switched doctors (when my son was around 6 months) he was diagnosed with reflux. The doctor did not order any of the tests to confirm he had reflux since she felt strongly based on the symptoms we described that he suffered from reflux. Please refer to the section below which discusses diagnosing GERD. Please refer to the "Feeding Tricks" article for tips on what we discovered to help our baby eat better when he was suffering from reflux.
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Symptoms
Refer below for a list which compiles the symptoms of GERD. I obtained the description of symptoms primarily from the CDHNF web site.

1. Crying – "arching away from breast/bottle with crying or irritability"^1,2


2. Frequent spitting up (although not all babies with GER spit up regularly)^2,3


3. "Feeding difficulties^1,2
   • Feeding refusal^1,2
   • Poor growth or failure to thrive¹
   • Difficulty eating (e.g., choking or gagging with feeds)"^1,2


4. "[P]ainful bursts of nighttime fussiness"^2,3


5. "[F]requent bouts of colicky, abdominal pain"^2,3


6. "Breathing problems^"1
   • "Repeat bouts of pneumonia"¹
   • "Breathing stops^"1
   • "Turning blue"¹
   • "Chronic coughing^"1,2
   • "Wheezing"^1,3
   • "[T]hroaty sounds" after feeding³


7. "Vomiting associated with"¹
   • "Blood (e.g., bright red streaks, blood clots or coffee ground appearance in stomach fluids)"¹
   • "Green or yellow fluid^"1
   • "Poor weight gain"¹
   • Projectile vomiting^2,4


8. Hiccups²


9. Spitting up milk through nose²

¹CDHNF, "Parent's"
²My son's symptom. Note: Hiccups and spitting up milk though nose was not found as a symptom in medical research, this was my personal experience with my son. This may not be a true symptom of reflux although when we tried to wean my son from his reflux medication I noticed he started getting hiccups again. For my son, there tends to be a correlation between hiccups and when his acid reflux acts up.
³Sears, "31 Ways"
⁴My son's original doctor told us to look out for reflux when my son was 4 months old by watching for projectile vomiting. At 4 months although my son was refusing to eat he was not projectile vomiting. Not all babies with reflux projectile vomit and as discussed by Sears ("31 Ways") some may not even spit up a lot.

Some of my son's symptoms like constant spit-up, spitting up milk through his nose, and hiccups were evident from when he was 1 month old while others like arching away from breast/bottle, feeding refusal, and gagging with feeds occurred when he was 4 months old. My son didn’t projectile vomit until he was older, around six months or so and he didn’t do that very frequently. My son coughed a lot, not a congested cold cough but a cough like he had something stuck in his throat. We use to think he was trying to get attention, little did we know it was due to the reflux.

My son was initially an excellent eater (with his bottle, breastfeeding was not as simple) until around four months and then he had very poor feeding when it came time to drink his bottle or breastfeed. He would cry when we tried to bring the bottle near his mouth. Or if he was drinking he would stop after about an ounce and get very irritable and start arching his back. He also would appear to gag or choke when drinking his bottle. The eating problems continued when at six months for two weeks he happily ate baby food and then he wouldn’t let us even bring the spoon close to his mouth. After switching pediatric doctors we were able to have my son officially diagnosed with reflux at six months and we subsequently started him on reflux medication.

Before the official diagnosis, I was able to help my son drink his bottle and breastfeed by using the "Feeding Tricks" described in that article. I also developed a "Top 10" on introducing baby food to help my son enjoy eating his baby food again. My son was in the 50th percentile for growth and weight for his first year and he stayed in the 50th percentile for growth but dropped back to the 25th percentile for weight in his second year. Once my son was on the medication and we used some of the feeding tips, I felt my son ate well again and by two years old he generally ate extremely well. Our doctor wasn't concerned with his drop in weight during his second year as he said genetics starts to play more of a role and my son's father was very slim as a child.
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Diagnosis
Many doctors diagnose the baby based on symptoms described by the parents. Although, if you want to obtain an official diagnosis, the following are some tests performed:

¹CDHNF, "GERD in Infants: Symptoms and Diagnosis"
²Sears, The Baby Book 390 - 391

Our doctor did not run any tests to determine if my son suffered from reflux. She felt very strongly based on our description of his symptoms that he had reflux. It was also evident that once we started him on medication he started eating his baby food again. He still didn't drink his bottle well until almost a year but I do feel the medicine helped with that as well. Later when we tried to wean my son off of the medication he would stop eating and drinking well and would become a more "needy" baby when normally he is extremely independent. For example, he loves going to my gym daycare but the week after I took him off the medication (and sometimes it takes a few days for the medicine to fully wear off) he would cry when I left. Soon as we put him back on his medicine he enjoyed the daycare again. I felt it was like any sick/ hurting child, since he wasn't feeling well he wanted his mommy and once he was well again he could be himself and play and have fun with the other kids.

I continually would ask my son's doctor if we should perform any tests to confirm if he had reflux. He said he doesn't like to do any of the tests unless the child is not growing well or there are other developmental delays. I also asked if I should see a pediatric gastroenterologist (GI specialist), a specialist who cares for children with digestive problems, and my doctor did not think it was necessary. Although, when my son was almost two and didn't seem to be growing out of his reflux and had a bad month of throwing up (primarily due to a cold, he was congested and when he coughed on the mucus he would throw up) I decided it was time to see a GI specialist.

I was extremely happy we went to the appointment. She confirmed again that based on the symptoms described my son seemed to definitely have acid reflux. She increased the medication we were giving him as she said the most important thing is to make sure his esophagus does not get damaged from the acid. In addition, she recommended we do the barium swallow X ray to rule out any other abnormalities that could contribute to the reflux. We did the test and the test was able to confirm that my son's internal system looked "normal" and I was happy to have spent the $200 to learn my son was "healthy" and hope that he will eventually grow out of his reflux.
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Treatment
Your pediatrician may recommend a trial of medication that decreases acid in your baby's stomach or refer you to a GI specialist. Our son was put on medication when he was six months old and was on it until about 2 1/2 when he finally seemed to grow out of his reflux. Before my son turned 2 1/2 we tried taking him off the medication several times but he usually would stop eating well and become "needy" when he was usually very independent. When my son was around 2 years old at a visit to the GI specialist she increased his medication as she said the most important thing is to make sure his esophagus is not damaged by the acid. Please refer to the "Medication" article for more information.

If the GERD is extreme then surgery may be recommended. There are also "lifestyle adjustments" that can help a baby:

1. "Avoid overfeeding"¹


2. "Don't feed the baby again after he or she spits up (wait until the next feeding time)"¹


3. "Check with your doctor to see if you are using appropriately sized bottles or nursing the appropriate amount of time"¹
• Our baby drank best with the Dr. Brown's bottles."
• Feed half as much twice as often."²
• Starting at 4 months, our baby would only drink a few ounces at a sitting and so we had to do frequent feedings to help ensure he drank enough for the day.
• "Feeding frequently stimulates more saliva production...[and] [s]alivia contains a healing substance...which helps repair the damaged tissues in the esophagus. It also neutralizes stomach acid and lubricates the irritated lining of the esophagus."²


4. If possible, breastfeed your baby
   • "[E]asy-in, easy-out" since it empties from the stomach faster and usually produces "softer and easier-to-pass stools"²
   • "Breast milk is more intestine friendly than formula."²
   • I was able to breastfeed my baby until around 6 months and had I known breast milk would have helped his reflux I would have tried to breastfeed longer. Unfortunately, my son's reflux contributed to weaning from breastfeeding early since around 4 months he didn't want to breastfeed (or bottle feed) and so I started doing more bottles so I could track what he was drinking for the day.


5. "If your baby is formula-fed, thicken the formula with a small amount of rice cereal"¹
   • We switched to oatmeal cereal as it was not as constipating as rice cereal was for our baby.
   • Try different formulas, our baby digested Nestle Good Start better than other formulas since it was 100% whey rather than the whey/casein mix of most formulas.
   • You may want to try a Hypoallergenic formula to see if your baby has a cow milk allergy.


6. Make sure you burp baby well as excess "air aggravates reflux"²
• For awhile, we were hesitant with burping our baby since he got so upset when we burped him but really that was the best thing for him. We found that if we gave him his pacifier when we were burping him that it helped.
• Try other bottles to help minimize air intake or make sure baby is properly latched on for breastfeeding.


7. "Keep the baby upright for at least 30 minutes after a feeding.^"1
• Wear your baby to help keep her upright; I think this helped my baby for the first few months.
• Try to not "jostle or vigorously play with baby after feedings"² I still try to remind our son's Daddy to try to not play too much right after our son (now almost two years old) eats but that is hard for both him and my son to follow.


8. Discuss with your doctor about positioning the baby at night to sleep. It is recommended to put the baby to sleep on her back to help avoid SIDS (Sudden Infant Death Syndrome) but if your baby is suffering from reflux you may want to discuss other sleep positions.
• We elevated our baby's mattress. You can also buy sleep positioners some of which are elevated for the baby. We should have bought one of these.


9. "Try not to let your baby spend too much time in a car seat (The baby's position in the car seat can promote reflux)"¹


10. "Avoid tight diapers and elastic waistbands"¹


11. Develop parenting style to promote attachment parenting to help decrease crying, "since crying puts pressure on the stomach which worsens the reflux"²


12. Pacifier use may help since "sucking stimulates saliva production"² unless the baby sucks too hard and swallows air then the air can make the reflux worse.
• My son always loved his pacifier and I was happy to let him use something that made him feel better.
• My son is almost two and I still let him have his pacifier for nap and bedtime. I plan to wean in the next year although since he is still suffering from reflux I'm reluctant to wean him. My son's pediatric dentist said we should try to wean him before he turns four. I don't think we should have a problem with that.


13. Help baby avoid constipation since "increasing abdominal pressure...can aggravate reflux"²
• Unfortunately, my son had constipation for most of his first year which probably didn't help his reflux.
• Oatmeal cereal was less constipating than rice cereal
• When starting baby food, make sure you avoid or limit the constipating foods like bananas, carrots, and applesauce.
• The "Constipation" article is coming soon

¹CDHNF, "GERD in Infants: Treatment and Management"
²Sears, The Baby Book 392 - 397

For other tips on how to help both you and your baby cope with reflux, please refer to the "Coping" article which is coming soon.
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End Note
The fact my son had reflux and subsequently developed feeding problems, which we were able to help him eat with "Feeding Tricks" and also "Top 10" with introducing baby food, was a strong contributing factor to why I started this web site. I did a lot of research on reflux and I wanted to share what I learned with others. Although, when it came time to publish this section, it was hard for me to finish writing the reflux articles. I think I had "lived and breathed" so much about reflux that I just didn't want to write any more about it. But I finally decided it was time to publish the articles as I want to share what I learned to help you along your parenting journey. I wish you the best of luck.

Please make sure you discuss any concerns you might have about your baby with your healthcare professional and remember "that with treatment, severe reflux and GERD can improve. A pediatrician or a pediatric gastroenterologist can help your child, and can offer you strategies for coping with GERD. Once your baby's GERD is under control, he or she should enjoy a happy, healthy childhood" (CDHNF, "GERD in Infants: Pediatric").
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Works Cited

Children's Digestive Health and Nutrition Foundation (CDHNF). "GERD in Infants: Pediatric GERD in
Infants." 1 April 2010 <http://cdhnf.org/wmspage.cfm?parm1=43>.

---. "GERD in Infants: Symptoms and Diagnosis." 31 March 2010
<http://cdhnf.org/wmspage.cfm?parm1=44>.

---. "GERD in Infants: Treatment and Management." 31 March 2010
<http://cdhnf.org/wmspage.cfm?parm1=36>.

---. "Parent's Checklist for REFLUX in Infants 0-12 months old." 29 March 2010.
<http://cdhnf.org/user-assets/documents/pdf/GERD_Checklist.pdf>.

---. "Pediatric Reflux and GERD." 29 March 2010 <http://cdhnf.org/wmspage.cfm?parm1=42>.

Children's Digestive Health and Nutrition Foundation (CDHNF), et al. "Coping When Your Baby Has
Reflux or GERD: You Are Not Alone." CDHNF. 23 March 2010
<http://cdhnf.org/user-assets/documents/pdf/Coping_Reflux_GERD_Guide.pdf>

Salvatore, Silvia M.D., and Yvan Vandenplas M.D. "Gastroesophageal Reflux and Cow Milk Allergy: Is
There a Link?" Pediatrics: Official Journal of the American Academy of Pediatrics.
110 (2002): 972-984. 30 Oct 2009 <http://pediatrics.aappublications.org>.

Sears, William M.D., Martha Sears, R.N., Robert Sears, M.D. and James Sears, M.D. The Baby Book:
Everything You Need to Know About Your Baby - From Birth to Age Two. New York: Little, 2003.

Sears, William M.D., Martha Sears, R.N., James Sears, M.D., and Robert Sears, M.D. "31 Ways to Get
Your Baby to Go to Sleep and Stay Asleep Easier." AskDrSears.com. 26 Jan 2010
<http://www.askdrsears.com/html/7/T070300.asp>.

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Last updated:  April 2010