Gastroesophageal Reflux

What is it? Since the name is so long, we usually abbreviate this by calling it reflux or GER. Essentially, reflux is excessive spitting up. Each doctor may have his/her own definition of “too much”. Most babies will have a wet burp with every meal. Most babies can spit up a mouthful at one or two meals a day, and we may consider this acceptable. When the baby spits more than a mouthful more than twice a day, then we usually would consider that something we should treat. How the baby is gaining weight will also be an important consideration when deciding to treat reflux. You may be wondering how we tell reflux from stomach flu or formula intolerance!

How reflux is different from Stomach Flu (viral gastroenteritis): With reflux, the baby is usually hungry after they spit, and they act well; with stomach flu, they are sick and not hungry. Reflux has nothing to do with the stools, but stomach flu almost always has diarrhea with it. Stomach flu often has a fever, while reflux never has a fever. Stomach flu only lasts a few days, while reflux may last several months (of course you will not know this in the first few days).

How reflux is different than formula intolerance: These two are actually quite similar, therefore we will have to decide which your child has after talking with you in detail. Formula intolerance often will have excessive gas, gas pain, and diarrhea - often with streaks of blood in it. When we think your child has reflux, we will often try different formulas anyway to make sure this is not part of the problem. Do not switch formulas without discussing this with us.

What causes it? Your esophagus is the tube that carries food from the mouth to the stomach. At the lower end of the esophagus is a collection of muscles wrapped around the esophagus called the Lower Esophageal Sphincter (LES). This LES is supposed to keep the stomach contents in and prevent spitting or vomiting. The LES does not function well until approximately 8-10 months of life. Some kid’s LES simply does not function as well as others.

How do we treat it? You and your doctor / nurse practitioner will decide which treatment to give. Do not change the treatment or try another step, unless we have instructed you to do so. The order of these steps is not necessarily the order you may try. You will notice that there are a lot more steps you can try when bottle-feeding. Breast fed kids do spit up much less often. For example, breast milk only takes 30 minutes to get past the stomach, while formula takes up to 2 hours. Of course, there are always exceptions.

• Lay the baby on the belly after feeding: We always lay babies to sleep on their back to help reduce the risk of SIDS. The only exception is kids with reflux, and then only after a feeding. After a feeding lay the baby on a bed that is on a 30-45 degree incline. Lay the baby with the head up, and place blankets around him so he does not spin around and get his head lower than the rest of him. This position is the hardest position to throw up in. Also leave the baby in this position, and don’t bother him for 20-30 minutes. Sometimes babies will spit up right after a feeding when we excite them. Occasionally, some babies with reflux will spit less in the sitting position in a swing.
• Change formula: If there are any signs of a formula intolerance, we might have you change formula. When changing formulas, we generally stick with the same brand. Most babies start on a milk based formula (Similac Advance, Enfamil Lipil, Good Start). If there is excessive gas, gas pain or diarrhea, we might go to a lactose free version (Similac Lactose-Free or Enfamil Lactofree). If this does not work, we might try a soy formula (Similac Isomil or Enfamil Prosobee). If there is still a concern that the formula might be an issue, we will go to a partially digested formula (Similac Alimentum or Enfamil Nutramigen).
• Make sure the baby is not swallowing air through the nipple: Make sure air does not get through the nipple when you are feeding the baby by ensuring that formula always covers the internal nipple opening. The Platex bottle and curved bottles are easiest to do this with.
• Burp very often: Some babies eat very fast and gulp air when they do. The extra air in the stomach will carry formula or breast milk back up with it when they burp sometimes. Burping every ½ ounce, or every 2 minutes or so, will often help this.
• Clean out a stuffy nose before feeding: When the nose is very stuffy, babies will gulp air when they feed. If you use saline nose drops and suction the nose before feeding, these babies will gulp less air. Also, try burping often.
• Try different nipples: If bottle-feeding, try a different brand of bottle or nipple. Some babies like the shape of one nipple more than another. There are also nipples with 1 hole and 3 holes. If your baby is sucking hard and fast and you are using a 1-hole nipple, he might be swallowing air, as the formula cannot get through the single hole quickly enough. In this case, try the 3-hole nipples, or poke extra holes with a hot, clean needle. In some cases, the 3-holed nipples could be delivering too much formula too fast, and this chokes the baby making them spit-up. In this case, try a 1-holed nipple or 2-holed nipple (buy 1-holed nipple, then poke an extra hole with a hot needle).
• Feed less more often: Let’s look at an example. A 10-pound child should eat 23-24 ounces per day (2.3 ounces per pound per day up to a maximum of 32 ounces per day at around 4 months of age). If that child were eating every 4 hours (6 times a day), he would be eating 4 ounces per feeding. The more food in the stomach, the more likely you are going to get spitting. Sometimes that last swallow is all it takes to stimulate a spit up. If this same child took 3 ounces every 3 hours (8 times a day), the total amount per day would be the same, but they would spit up much less.
• Thicken the feedings with Rice Cereal: Thickening the formula will make it harder for the stomach to throw it back up. Only use rice cereal, not oatmeal, rye or barley. All rice cereal is iron-fortified. Do not use the rice and fruit version. Mix 1 to 2 tablespoons of rice cereal per ounce of formula (example 4 TBS rice for 4 ounces of formula). Studies show that adding less than 1 TBS per ounce is not effective for reflux. Using more than 2 TBS per ounce makes it too thick. Make sure to use a feeder nipple, or cut a slit in the nipple with a razor blade, or the thickened formula will not flow through the nipple, the baby will swallow a lot of air, and the spitting will get worse.

What else can we do to help? There is definitely more we can do, but anything beyond that outlined here will either require a prescription, possibly testing but not usually, or will require face- to-face discussion to ensure proper treatment. Prescription acid blockers are very effective at treating reflux and are very safe.

When should I call the doctor? There is a bowel disorder called Pyloric Stenosis that looks like reflux when it first appears. The pylorus is a muscle wrapped around the gut just past the stomach. This muscle keeps food in the stomach until the stomach can break down some of the food. In Pyloric Stenosis, the pylorus muscle grows so big that it won’t allow anything to pass. This usually occurs in first-born males, but can occur in any baby. Pyloric Stenosis usually shows up between 3 and 6 weeks of age as progressively worsening vomiting. The vomiting is projectile. Projectile is a word that frequently gets used incorrectly. In this case, when we say projectile, we mean shooting out of the mouth like a garden hose on full pressure stream that can shoot the vomitus several feet away from the baby. Many people will describe vomitus gushing out of the mouth as projectile, and this is not correct. With Pyloric Stenosis, eventually everything that goes in the mouth will come back out, and the baby will get dehydrated. If you think your baby has this, then call us immediately.