Gastro oesophageal reflux

and the breastfed baby 
ABM > Specific need/experience > Gastro oesophageal reflux and the breastfed baby

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What is reflux?

Many babies bring milk back up through their food pipe at different times of the day or night. This is called reflux (short for Gastro-Oesophageal Reflux, or GOR). Simply put, the valve between the stomach and the food pipe (oesophagus) is not keeping the baby’s milk down and it comes back up the pipe the wrong way. Silent reflux is where milk comes back up from the stomach, but is not vomited out, and is swallowed instead.

Reflux usually begins before 8 weeks old, often declines after 6 months and disappears by itself by the time babies are a year old. At least 40% of babies bring up about one feed each day and around 5% of babies will reflux 6 or more times a day, without any other problems.

Babies with reflux may also cry a lot or be uncomfortable or irritable. They may have lots of hiccups or coughs or be difficult to settle due to the reflux.

Even though reflux is often a normal part of infancy, it can be very hard for parents whose babies frequently bring up milk, as they may seem distressed or uncomfortable. Reflux doesn’t generally need medical investigation and is often managed through feeding and positioning advice and reassurance.

What can cause reflux?

For most of human history, babies were not left lying down, as this would put them at risk of harm, so they would be carried and held all day. Now that we routinely lie babies down much more than our ancestors did, gravity from being constantly upright isn’t helping to keep babies’ milk down in their stomachs, and it can come back up.

Babies who are not latching effectively for breastfeeds may have reflux. This can be because they are taking in air when feeding or when crying. Sometimes, babies just need to be in a slightly different position to latch more deeply. Sometimes it can be a result of physiological issues such as a tongue tie.

Babies who have an allergy may have reflux as a symptom, or reflux may be a symptom of microbial dysbiosis – an imbalance of gut bacteria. Reflux is more common in children with asthma, though asthma isn’t a cause of reflux; they may both be symptoms of allergy, however.

What can make reflux worse?

  • Being in a household with a smoker.
  • Spending time in slumped positions such as car seats.
  • Tight clothing around the stomach.
  • Lying down after a feed.
  • Overfeeding, or large, infrequent feeds
  • (which is more likely when bottle feeding).
  • Maternal food choices, such as excess caffeine.
  • Tongue tie if it affects the baby’s latch.
  • Cows’ milk protein allergy.
  • Fast let down reflex (also known as the Milk Ejection Reflex).

When should I be concerned?

Whenever you are worried about your baby, you can contact a health professional such as your G.P., midwife or health visitor for support. A health professional may want to investigate further if your baby has other symptoms such as unexplained lack of weight-gain, severe distress, or very forceful and frequent regurgitation, spitting up green/yellow fluid or what looks like coffee grounds, blood in baby’s poo or baby repeatedly refusing feeds. If your baby seems not to be keeping any milk down or is showing signs of high temperature, dehydration or fever, always seek immediate medical advice.

How can I help my baby to be more comfortable?

As ‘carry mammals’, we are designed to hold our babies upright for much of our waking hours and sleep close to them. Frequent breastfeeding and being responsive to baby’s cues will help to minimise baby’s crying. Little and often feeding works well for many babies, especially those with reflux.

Getting trained support to improve any latch issues and making sure the baby is feeding effectively, perhaps with a more upright feeding position will help to ensure that breastfeeding is going as well as possible. After feeds, ideally keep baby upright against their carer for at least 30 minutes.

Patting to wind may make the reflux worse, so simply hold baby with their head on your right shoulder and their stomach in the middle of your chest. It is better to avoid bouncing or jiggling the baby at this stage.

Bouncy chairs and car seats curve the baby’s body, which may make them more uncomfortable. Try to limit the time spent in these and where possible, avoid them after feeding.

Safe sleep guidelines state that babies sleep on a flat surface. If your doctor recommends that you raise one end of their cot or crib, use a crib designed for this purpose in accordance with the manufacturer’s guidelines, rather than raising the mattress within the cot. Be careful to make sure that any incline is small, so that baby can’t slide down the cot; don’t use pillows or anything that interferes with a flat sleeping surface, and always place them feet to the foot of the cot.

Sometimes, an elimination trial of dairy from the mother’s diet can help reduce baby reflux; keeping a food diary can help spot patterns in case there are any other food intolerances to be considered. Elimination diets are best done with support from a health professional.

What is GORD?

Gastro-oesophageal Reflux Disease may be diagnosed when several of the following are happening together: baby not gaining weight, frequent and forceful vomiting, distressed behaviour and/or recurring coughs, hoarseness or pneumonia. Babies who were preterm, who had hernias, or who have a neurodisability are more at risk of developing GORD.

How might my baby with GORD be treated?

All of the suggestions about how to make baby more comfortable should be considered. The NICE guidelines state that a review of feeding history should first take place, and smaller more frequent feeds may be appropriate. A breastfeeding assessment should take place for breastfed babies – a trained breastfeeding counsellor or International Board Certified Lactation Consultant can offer this support. If the baby is also having formula milk, then a review of how the feeds are prepared and techniques used for giving them should be undertaken.

Around 25% of babies with GORD also have cows’ milk protein allergy (CMPA), which can be managed through a change in maternal diet for breastfed babies.

If feeding advice does not reduce symptoms, then a trial of alginate therapy may be given. This should be stopped at intervals, to see if symptoms have reduced. The next step treatments for babies with reflux in addition to unexplained feeding difficulties, distressed behaviour or faltering growth may be a trial of proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs). All medicines can have side effects, so it is important to discuss this with the prescribing doctor.

Does my baby with reflux need to stop breastfeeding?

Ideally, a baby with reflux should continue to breastfeed. If your baby may be allergic to cows’ milk protein, then an elimination trial of all cows’ milk from the mother’s diet may help to improve symptoms (under medical supervision). If an allergy is found, then revisiting maternal milk consumption via a ‘milk ladder’ approach may be suggested.

Where can I get more support?

Looking after a baby who is regurgitating milk often or who is uncomfortable and unhappy is difficult for parents. Making sure that you have someone to talk to about how you feel can be important. This could be face to face, whether a loved one or at a support group. You may also find an online group helpful for practical tips as well as emotional support.

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