The Management of Reflux in the First Year
by Anke Tillman September 2015
Physiology (/ˌfɪziˈɒlədʒi/; from Ancient Greek φύσις (physis), meaning “nature, origin”, and -λογία (-logia), meaning “study of”) is the scientific study of the normal function in living systems. A sub-discipline of biology, its focus is in how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. Wikipedia
I want to start with this definition and claim quite frankly, that newborn reflux is something totally physiological. It shouldn’t cause any suffering to babies though, but a lot of times it does, and then, of course, it needs to be addressed. But having to take action because of it in the first months of a babies life, is still is not something pathological. There are many possible reasons for this reflux, that we may consider normal.
Examples of ‘normal’ reasons for reflux in an infant:
- an immature lower esophageal sphincter
- delayed gastric emptying
- tethered oral tissue (tongue & lip ties)
These are not diseases; these are things that may happen to babies. Some have a harder time adjusting to the outside world than the other. Things like swallowing too much air can make all hell break loose. Or, dairy in mom’s diet can make all hell break loose. Also Lip/tongue ties. There are several factors that may be worth addressing.
In these awfully exhausting times, it is the parents’ job to evaluate the situation and see how they can help. Of course, each parent does this, and intuition usually steers moms and dads in a good direction. Pretty soon the pediatrician gets involved, and a lot of times a pediatric GI as well, which I think is totally right; the GI should be the one involved. He should coordinate any lifestyle changes and, if necessary, medical treatment. Most babies can’t do it without the help of a GI, even though a lot of literature claims they should! This is ridiculous, perhaps this was the case in the old days. [infantreflux note: PLEASE contribute YOUR Ped GI reviews! And Click here to search to find one.]
Today we have medication to alleviate the effects of acid reflux on babies’ system and they should be used. They can only outgrow something if they have a chance to eat and sleep right. Yes, there is controversy about the use of PPI in infants, but there are not many other options. And since stomach acid is not only causing heartburn, abdominal pain and sleep issues, but also long term damage to the esophageal lining or reoccurring upper respiratory infections, it needs to be treated, no question about it.
Finding the right brand, dosage, and way to administer is the next challenge. The focus should be on THIS. Finding the right PPI should not be given up after one or two attempts, like “oh, we tried a PPI, it wouldn’t help at all.” NO. PPIs are the only option of treatment here. We have to make them work, and eventually they will. Sometimes babies are on an H2 Blocker first, or in combination with an PPI. Well, medical management of the reflux is the major thing to pursue, for the next months to come. Every month the child gets older, chances are she will outgrow reflux. So, the use of PPIs should be established in a treatment plan, and monitored by the GI.
Ideally, the GI would be one who is advanced in the use of PPI and dosing, however the reality of how well versed a GI is differs much of the time. Sometimes these GI’s don’t give it too much thought and jump onto to the testing train right away. They want to do something, they want to be helpful, but they also want to RULE OUT. Whatever it is that they are trying to find, it is not something that would be treated much differently if they weren’t looking in the first place. The only truly major important thing to rule out is pyloric stenosis. Ruling this out can be done easily by a very smooth and non-invasive abdominal ultrasound.
Don’t have a scope on a two month old! That is what a lot of doctors order, and I don’t get it. I also don’t understand pH studies and upper GI’s being done on tiny infants! In a two month old, reflux is normal. Immaturity does not show up in these tests. They may confirm reflux, but they may not! Don’t we know our baby has reflux when baby throws up on our shoulder? Do we need general anesthesia or barium swallows to confirm it IS reflux? Is a tube in baby’s nose for 24 hours necessary to confirm she is having regurgitation?
By two months of age, there are really not many answers you may get out of these tests. They only cause major discomfort, unnecessary radiation and even more flares from all the stress they cause in the little ones. A baby has more benefit from being left alone, with all focus and efforts on medical management of the reflux, managing the proper diet as well as ‘lifestyle’ changes. LOVE and sleep are also very important things, that make babies thrive. The vicious cycle sometimes begin when sleep deprived moms are getting weak in their confidence in knowing their own babies. Then they get nervous, and may lose the big picture. Always listen to yourself. Is your baby really sick, does she have a serious condition that needs to be diagnosed and treated, or do you feel it is just a struggle getting an immature digestive system to work properly? Usually your intuition can answer you this, depending on how far you already are, in the nightmare of carrying your child around constantly, eating unexceptional fast food yourself and not even noticing spit up on your clothes.
When we are closer to the six (6) month mark, and the reflux is still there and causing problems, then it may get time to find more answers. It is important before that age to give it a chance to calm down. By six months of age, with lifestyle changes, dietary adjustments and medical treatment, there should at least be a tendency towards improvement. If not, it may be time to start testing. If parents have second thoughts, because even 6 months is still very little, it is very reasonable. I don’t see any problem in waiting even longer, as long as the parents can justify holding off. By this I mean there should be weight gain, and the quality of life must be acceptable for the baby.
How long does this last??
[From the Facebook group] “They” tell you three months to keep you sane. then 6 months. then 9 months. Most of the folks here are cases where it takes a bit longer- most mamas come here, get things under control & disappear.. then, of course, you have those who stick around to help others, like ME 🙂 so the ‘general’ amount of time is ~12 months. PAIN is the most important thing to address and then ROOT CAUSE! If there’s still pain and no root cause by 12 months…it is quite likely time for testing.
[Anke T. replied]: I have to totally agree to the 3-6-9 month statement. I should have counted the providers that stated with all confidence in the world “he will have it outgrown by x months.” They refer to it as IT in terms of not really knowing what they are talking about, since most parents with severe reflux don’t even have a proper diagnosis for their child, despite GERD, which does only define symptoms, not cause. Even after the 12 month mark and knowing that my son had a hiatal hernia and 126 reflux episodes in 24 h, some doctor and his NP claimed “but he may outgrow it”. The office manager was present and said “are you guys serious about this?” They seem to be programmed to say that over and over, and may believe in it themselves. The journey was over for one of mine at 18 months, when he had his surgery. But I have another little guy running around here, he is 5 years old and has not grown it out. We are still working on that one. My oldest had extra esophageal reflux and recurrent bronchitis, croup and pneumonias. He never ate. By age 7 years (!) he seriously outgrew it. I was desperate by that time, and like a miracle, it stopped. He started to eat and was never hospitalized again. But it is hard to wait for the outgrow moment, until then at least a proper diagnosis should be there.
…When you start the testing cascade, you should have diagnosis in mind that you either want to be confirmed or ruled out…
However, it may be time to look for the culprit, since the physiology of newborn reflux would include improvement. But when it comes to testing, now it is even more up to the parents, to advocate for their child. Some doctors just unload their arsenal with a battery of tests that may not always make sense in every child. Do your homework. Google! Research procedures here! Get signed up into support groups, read everything you can about GERD in infancy. By the time you consult the GI about testing YOU should already know which one of the tests would reveal the most conclusions. It may be the EGD, the scope, if you suspect any abnormalities in anatomy. Or, if you decide to go with that, because it also takes biopsies, and there may be possible answers from that. There may be esophagitis and you may want to know to what degree. For every test you think of, ask yourself first what answers you would possibly get out of it, and if or how this will affect the treatment plan. There is no sense in invasive testing, if nobody pays attention to the results in any way. When you start the testing cascade, you should have diagnosis in mind that you either want to be confirmed or ruled out. If you had a test done, and it showed everything normal, which is very likely to happen with a EGD in a 6 month old, don’t give up. Think precisely about the next step. Don’t let the doctor brush you off. Sometimes I suspect a little, that this is the reason why they scope two month olds. They may have the best intention, by making the parents feel they took action, they did an extensive test, one that did not show anything, so Baby MUST be all right, and now parents will shut up and take it for the next months to come. In my experience, this is not the right means of reassurance.
Never go to a doctor’s appointment unprepared. These turn out the worst. Doctors are only human beings. And, some of them may even have a reflux child as well. These are not necessarily are the ones with the most compassion. If they do not have a reflux-child themselves, they have a personal life, or just a bad day that can affect them. And, while they shouldn’t take it out on patients, and they most likely try not to do that, they may not be at their peak performance that day, and, unfortunately it is your turn when it comes time for them to vent their misery. You may have waited a long time for this appointment. And now, it can all go downhill fast.
Try to keep it simple, rational, list facts. Always know exactly the 24 hour intake in oz. Bring photos of puddles they spat up, or poop. Make a list for yourself, and stick with it. You have to know exactly what outcome you need from this appointment. Is it a certain test you want to schedule, is it a condition you want to ask about, do you need a prescription or more than one prescription? Ask, ask, ask and don’t complain. You have friends or your mom for the complaining. I know this sounds rude. But you will never get anything out of these appointments, if you don’t see them as a resource that should not be wasted at all. You made all the effort going there, dressed up the little spitter and got an earful from the car seat all the way there. And back. Or a power nap from exhaustion that will ruin your already very fragile schedule. So make the most out of it.
You are Baby’s voice, they can not speak up for themselves yet. So think twice; don’t always agree to everything. You are the parent; don’t pass the responsibility out of your hands. You can always tell the doctor that you will think about something, then call back and give your answer later. Testing is important, but it needs to be done with precision, and all symptoms considered. And then taken step by step, all results worked into the treatment plan. General anesthesia is rough, the younger the baby the worse it is. It may always work out fine, but you as a parent will also live with any consequences for the rest of your life, and you wrote your name under this at the consent form.