Thursday, 28 May 2015

Reflux and breastfeeding

Reflux - it's a biggie.  There's a good chance that in the early weeks of your baby's life you will wonder if he has reflux, or have it suggested to you.  You likely know other babies who are on medication for reflux.  It almost seems that reflux is queried now for any fussy feeding or unsettled behaviour, but is anyone actually looking at why that baby is unsettled?  Reflux exists of course, but is it a medical problem, and do all these babies need medicated?  I believe that many cases of reflux are actually indicating a feeding issue, and have non medical solutions. This blog will concentrate on breastfeeding and reflux, but in fact the principles are applicable to any bottle feeding too.
Reflux is common and physiologically normal.  The NICE guidance describes it as follows, 


"Gastro-oesophageal reflux (GOR) is a normal physiological process 
that usually happens after eating in healthy infants, children, young people and adults...
GOR is more common in infants than in older children and young people,
and it is noticeable by the effortless regurgitation of feeds in young babies."

Babies are different from adults.  When an adult vomits it's generally a sign that something is wrong, and with no one talking about the normalcy of reflux in babies, mums feel something is wrong with their baby.   The NICE guidance suggests that 40% of babies spit up/vomit, and for the vast majority of babies it is a laundry issue, not a medical one.  
Some babies are diagnosed with  'silent reflux' where milk begins to reflux back towards the mouth and either doesn't make it as far as the mouth, or is reswallowed once it gets there.  Sometimes a mum hears swallowing or sees other symptoms like baby hiccuping and perhaps eyes reddening.  Sometimes there are no visible symptoms of milk movement at all and reflux is diagnosed simply from crying, back arching, pulling on and off the breast ( which is sometimes misdiagnosed as breast refusal).

A common picture is that a mum with a concern visits her GP.  After a discussion around symptoms baby is often started on a milk thickener, and so starts the medication cycle.  It is difficult to administer to a breastfed baby as adding it to breastmilk digests the thickener.  This makes you wonder about the efficacy in the stomach!  Thickeners make many babies constipated and the now constipated baby has tummy pain and is more unsettled and fussy.  This often becomes confused with more reflux symptoms and so the baby is moved on to the next level of medication - proton pump inhibitors which reduce stomach acid.

Can we all just take a step back? Imagine your washing machine is leaking.  Each time you wash a load of clothes you see a puddle of water gathering on the floor.  You call a plumber and explain about the puddle of water.  Your plumber diagnoses a leak and suggests you change a valve to reduce the amount of water which fills the machine.  Now when you use the machine the puddle is smaller but your clothes don't seem to be washed properly either.  Is that an acceptable solution? 
You call a second plumber.  This time the plumber comes to your home and observes a wash.  He pulls the machine away from the wall so that he can observe the entire water cycle and notices that one of the pipes is loose.  He fixes it.  No more puddle. Your clothes get washed, the floor stays dry and everything works as it should because he understood what was causing the problem and removed it, rather than working on the symptoms.

Why are we not looking for the root cause of a baby's reflux?  Why are we managing symptoms?  Deal with the root cause and maybe we can eliminate the problem with reflux.



So what are the root causes?
1.  It's a baby -  The spitting up may be entirely normal.  Babies have little core strength and many spend a lot of time either semi horizontal or horizontal.  They have a liquid diet and can have an immature valve closing the top of the stomach, so that makes it leaky.  It's a bit like half screwing on the top of a bottle of water and then laying it down.  The water is going to leak back out of the top.  This normal physiological reflux generally resolves in time as the baby begins to sit up and moves to solid food.  In the mean time it may actually be beneficial.  The Canadian paediatrician Jack Newman believes that spit up may be a good thing in an otherwise healthy, content baby as it coats the oesophagus twice with antibodies - once on the way down and once on the way up again. The NICE guidance is very clear that either spitting up or silent reflux in and  of itself is not a problem and should not be medicated without other symptoms being present.

2.  Aerophagia - This is a medial term which just means swallowing air.  This is a huge cause for many cases of reflux.  A baby who is clicking, gulping, spluttering may be taking in air.  A baby who has a sub optimal latch may be taking in air.  Scheduling feeds and feeding on a very full breast or expressing for a freezer stash can create issues with swallowing air, as can a tongue tie or a birth issue.  In my previous blog I talked in detail about why a baby may swallow air during a feed so if you missed it click here.  As the air comes back up, milk comes with it.  The resolution for this is to correct breastfeeding management, or resolve the structural issues so that air isn't swallowed.  Without the air being swallowed the reflux can be eliminated or reduced to a manageable level.  Having a good breastfeeding assessment will help to optimise feeding and identify any issues with air intake.

3.  Low Milk Intake - This is more usually applicable to silent reflux where the diagnosis has come from symptoms of back arching, pulling on and off the Breast (which may have been misdiagnosed as breast refusal), and poor weight gain.  The poor weight gain is sometimes considered to be due to "silent reflux" causing pain, however the most common cause of poor weight gain is lack of calories so this should be investigated first.  Where milk supply is low the flow of milk is slow.  It is a very common behaviour for a baby to arch, pull on and off the breast and cry in frustration when flow is slow.  Milk volume is a complex interaction  of both mum and baby so low supply could be due to ineffective transfer from mum to baby due to birth interventions, something anatomical, poor latch, or baby not being at the breast enough.  Resolution would be to increase supply in mum and ensure baby is transferring effectively.  A good breastfeeding assessment and support can help to get things back on track.

4.  Allergies/intolerances - This is a more complex picture.  Sometimes where a baby is combination fed, reflux can result from issues with formula.  Where a baby is exclusively breastfed there can be issues with mum's diet.  In our society we are very dairy and gluten based, both of which are very allergenic foods.  Some research studies have found that milk proteins can pass through Breastmilk entirely unchanged.  The reason for this isn't clear.  Perhaps it is due to mum's own gut having damage from early introduction of dairy or solids, perhaps it is due to modern processing of milk, or maybe due to genetic changes in milk.  Regardless of the reason, many mothers do find that reflux symptoms improve if they remove dairy from their diet.  Some are fine with cultured products like cheese and yoghurt but not milk, and some need to remove all dairy.  Some find this is only temporary and once older baby can tolerate the food.  Getting to the root of the intolerance and removing it from the diet improves the reflux symptoms.

5.  Gut microbiome - Our gut bacteria is a huge topic of research at the minute.  We have more bacterial cells in our bodies than human cells and a healthy microbiome is necessary for digestion and for immune function, among other things.  A recent small study in adults showed that GORD (gastro oesophageal reflux disease) was associated with pathogenic strains of bacteria in the oesophagus.  Other studies have shown an improvement in reflux symptoms with probiotic supplements. 

6.  Baby's habitat - A baby is extremely immature at birth, with a nervous system reliant on mum's body.  If a baby is not in contact with mum, digestion does not work optimally.   We have been primed to believe that we need to set a baby down after feeding, not to spoil our babies, or create rods for our backs.  When a baby is separated from mum however the baby can become distressed, and emotional stress can lead to vomiting.  This may explain why baby wearing / carrying baby also seems to help with reflux.
Usually babies are not bothered by reflux, but they do receive emotional regulation from their mum.  If mum is worried, stressed and scared by watching their baby spit up, baby becomes worried and scared due to mums reaction.  This can start a cycle of anxiety and distress with spit up.  The normal reflux can then be misdiagnosed as GORD due to the baby's distress.  A good breastfeeding assessment should involve counselling about what is normal, and concentrating on mum's concerns and fears just as much as the baby's feeding.

NICE guidance is very clear on where normal reflux becomes something which needs investigation.


"in well infants, effortless regurgitation of feeds... 
does not usually need further investigation or treatment"

For silent reflux it states the following:


"Do not routinely investigate or treat for GOR if an infant or child 
without overt regurgitation presents with only 1 of the following:  
  • unexplaied feeding difficulties (for example, refusing to feed, gagging or choking)
  • distressed behaviour
  • faltering growth
  • chronic cough
  • hoarseness
  • a single episode of pneumonia"

If a baby meets the criteria for further investigated, the guidelines are also clear about what should happen next:

" In breast-fed infants with frequent regurgitation associated with marked distress,
ensure that a person with appropriate expertise and training
carries out a breastfeeding assessment."

Is this happening?  If your baby was diagnosed with reflux were you first referred to a person with appropriate training to carry out a breastfeeding assessment?

What's wrong with the medications?
Most mums don't feel comfortable with the idea of medicating their tiny baby, and side effects of the drugs are often not discussed in depth.  Thickeners often have a side effect of thickening stools or causing constipation.  Proton Pump Inhibitors (such as Losec) or H2 blockers (such as ranitidine)  reduce stomach acid.  These do not stop the reflux (in fact vomiting is listed as a side effect).  Reducing acid may initially seem like a good idea, but we have stomach acid for a very good reason. Our bodies need an acid environment in  order to digest proteins, and it also acts as an immune defence against pathogenic bacteria which are destroyed in an acidic stomach environment.  It also suppresses appetite.  In cases where the issue is low milk intake the drug may seem to help for a while, but the supreased appetite can mean that baby takes even less milk from the breast, and mums supply lowers  further and then the issue begins again.  Itt affects absorption of vitamins and minerals in the gut and some studies have found increased risk in respiratory illness.  With these side effects, and the clear guidelines from NICE, doesn't it make sense to investigate fully before considering drugs?

There is no doubt that some babies do have GORD.  These are very unhappy babies, and they need our help.  They may indeed need medication, but they also need help with breastfeeding.  Those babies are in the minority though.  Most babies probably don't need medication, but they absolutely do need good breastfeeding support.  A thorough breastfeeding assessment should involve observing a feed, optimising latch, and looking at a complete history of feeding so far.  It should consider baby's ability to transfer milk, weight gain and pattern of feeding through the day, any extra expression that happens regularly, how birth went and if there could be subtle effects, mum's feelings around breastfeeding, pain or discomfort, concerns or fears etc.  It should considers mum and baby as a unit and is much more than treating symptoms.  A breastfeeding counsellor or lactation consultant should also know when reflux is more than a feeding issue and does need medical help.

 Reflux is distressing -  for the whole family, and our babies deserve to have someone take the time to investigate and treat the cause, not just symptoms.


"For every effect there is a root cause. 
 Find and address the root cause rather than try to fix the effect, 
as there is no end to the latter." - Celestine Chua




www.carolsmyth.co.uk
 

Further Reading

NICE Guidance on reflux and GORD
http://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-recognition-diagnosis-and-management-in-children-and-young-people-51035086789

Gut Microbiome
http://midwifethinking.com/2014/01/15/the-human-microbiome-considerations-for-pregnancy-birth-and-early-mothering/
http://www.ncbi.nlm.nih.gov/pubmed/16437628
http://www.ncbi.nlm.nih.gov/pubmed/24424513

Baby's digestion and need for Skin to Skin
http://www.kangaroomothercare.com/olanders.aspx











4 comments:

  1. This comment has been removed by the author.

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  2. Just to be aware ranitidine is not a proton pump inhibitor it is a h2 antagonist. It has a different mechanism of action and different side effects.

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  3. This comment has been removed by the author.

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  4. Usually babies are not bothered by reflux, but they do receive emotional regulation from their mum. If mum is worried, stressed and scared by watching their baby spit up, baby becomes worried and scared due to mums reaction. This can start a cycle of anxiety and distress with spit up. The normal reflux can then be misdiagnosed as GERD due to the baby's distress. A good breastfeeding assessment should involve counselling about what is normal, and concentrating on mum's concerns and fears just as much as the baby's feeding.

    ReplyDelete