Reflux in babies?

Gastroesophageal Reflux (GER)

As with everything else anatomically in a baby, the stomach and esophagus also need to develop. The sphincter from the stomach up to the esophagus will be immature to start with, therefore weak and will open more frequently than an adult’s. This is useful as it acts as an escape route for the air that is ingested during eating. By around 6 weeks of age, the sphincter will have the same strength to close as an adult’s.

If the milk has been in the stomach for several hours before coming up, the regurgitation will be more lumpy and smell sour. This is especially where we as osteopaths will go in and look at what is causing the dysfunction.

Gastroesophageal Reflux (GER) (backflow from the stomach into the esophagus) is a normal physiological process in babies from 3 weeks to 12 months old. It is symptomless and can occur up to 30 times a day. It can be seen both by the baby swallowing and thus swallowing the milk again or by visible regurgitation/vomiting where the milk comes out.

Regurgitation is normal in over 50% of healthy infants between 0-3 months old, but is only seen in 5% of 10-12 month old babies.

Esophageal sphincter (LES)

​Gastroesophageal Reflux Disease (GERD) occurs when there is frequent regurgitation, persistent discomfort and complications.

The lower esophageal sphincter (LES) is a ring-shaped muscle located at the base of the esophagus that acts as a one-way valve between the esophagus and the stomach. Its primary function is to keep stomach contents out of the esophagus and windpipe. Its function is controlled by our autonomic nervous system via the vagus nerve (digestive nerve) and its movement is therefore involuntary. Weakening of the sphincter can lead to GERD.

The LES is normally in a closed position to prevent the mixture of stomach acid, digestive enzymes, and bile from rising up into the esophagus or windpipe. While the stomach is built to withstand the high acidity of stomach juices, the esophagus is not. Its lining is slowly eaten away by stomach acids, sometimes resulting in a painful sensation in the chest and throat often referred to as heartburn or acid reflux.

Hidden baby reflux

Silent reflux is part of the GERD diagnosis. (see the section on baby reflux) Here there is no visible regurgitation that comes up, but stomach acid and milk from the stomach that comes up into the esophagus, but instead of it coming out as regurgitation, it runs back and down into the stomach again. Therefore, it can cause double problems as the stomach acid and milk irritate the mucous membrane in the esophagus both when it runs up and runs down again.

​It should be noted that silent reflux is a concept that arose without pediatric studies to verify the existence of such a diagnosis in infancy.

This will be painful for the baby and will therefore be clearly bothered by it and cry a lot. But many have difficulty discovering that it is silent reflux, as there is no visible regurgitation, here it is important to look at how the baby is doing and what symptoms the baby has. (See also the section symptoms of baby reflux). It is important to know that a baby can have both Reflux and silent reflux at the same time, so that sometimes regurgitation comes up and at other times it goes up/down.

Good advice against baby reflux disease

• Keep the baby vertical/elevated for 20-30 minutes after a meal and do not roll around.
• Left-sided laying when baby sleeps, but only under parental supervision.
• Elevated headboard to 25-30 degrees.
• More frequent and smaller meals
• Thickening milk and other liquid foods with, for example, carob seed flour. (be careful, this can cause an upset stomach/constipation)
• Mothers can try to avoid foods that provoke reflux (chocolate, peppermint, caffeine, and fatty foods).
• Avoid exposure to tobacco
• After consultation with a pediatrician, a 2-4 week trial of a cow’s milk protein-free diet for the mother or hydrolyzed infant formula can be tried (up to 40% of children with reflux have a food protein allergy). Since children often outgrow the allergy, one can try reintroducing milk into the diet at 12 months of age.
• When the baby is over 1 month old, the baby should lie on his stomach for at least 20 minutes a day.
• Frenotomy (cutting of the tongue): May reduce pain associated with breastfeeding but no evidence of effect on GER/GERD or on establishing breastfeeding.
• Probiotics: A single randomized trial has shown a reduction in the frequency of regurgitation episodes with the use of probiotics. The evidence is weak, but due to the benign side effect profile, probiotics can be used as adjunctive therapy. Probiotics cannot be considered a treatment for GERD in themselves.

Causes of baby reflux

There may be decreased tension of the lower esophageal sphincter (the sphincter muscle between the stomach and the esophagus – LES). Infants eat much larger meals than adults, which will automatically cause a decreased tension of the sphincter. In an adult, a liquid meal will be out of the stomach within 30-60 minutes. But in infants, it remains in the stomach for 2-3 hours after a meal.

Additionally, babies have slower bowel movements, moving half as fast as an adult’s. When the esophagus becomes irritated, contractions in it stop, impairing the movement of food down the esophagus to the stomach.

Prolonged baby constipation can cause the baby’s stomach to be too full, making the baby more likely to get reflux.

Premature babies and children with neurological diseases may have a permanently reduced tension of the stomach mouth. The regurgitation will decrease during the first year of life as the food automatically becomes firmer and the child will be in an upright position more than as a lying baby.

Why does a baby get reflux disease?

The reduced tension can also come from a lack of firing from our autonomic nervous system via the 10th cranial nerve, the vagus nerve (our digestive nerve). The lack of firing often occurs due to pressure on the skull during birth (due to strong contractions, long/rapid births, taken by vacuum or caesarean section) or long-term lying down and pressure down into the pelvis in the latter part of pregnancy.

This means that the transition surfaces of the skull plates can become tight/overlap and press on the cranial nerves, for example the vagus nerve.

We also see that babies often have tension in the neck where the nerve also runs through, as well as locking/tension in the thoracic spine where the entire esophagus runs and the sympathetic nerve connection to the esophagus is located.

In addition, the diaphragm muscle (the diaphragm) plays a very important role in relation to reflux. If the diaphragm is very tight, its fascia (connective tissue) will pull on various ligaments, including the esophagus, thereby causing dysfunctions in the LES. Just below the diaphragm is the stomach. The stomach is connected to the diaphragm via a ligament (gastro-phrenic ligament). If this ligament becomes tight, it will pull the stomach upwards, which then increases pressure on the LES and thus increases the tendency to regurgitate. The diaphragm can, among other things, become tight due to locking from the neck. This is because we have a nerve (phrenicus) that comes from the middle vertebrae of the neck (C3-5) that is supposed to provide information to the diaphragm.

But you should also be aware of;

• Taking antibiotics (either during pregnancy/breastfeeding or if the baby has been given them) can cause disruptions in the intestinal flora.
• Stress (e.g. the mother may be stressed during pregnancy or the baby during childbirth), again disturbances around the vagus nerve (digestive nerve) which is responsible for the relaxing part of our nervous system (parasympathetic).
• Short/tight tongue tie (baby swallows too much air during feeding and lack of stimulation of the glossopharyngeus (sucking nerve) and vagus (digestive nerve))
• Passive smoking and caffeine relax the sphincter between the stomach and the esophagus.

Symptoms of baby reflux

An average baby cries about 2-3 hours daily with a maximum of crying at 6-8 weeks of age.

Symptoms of GER are frequent episodes of regurgitation. However, crying/irritability/pain, feeding difficulties with rejection of the breast or bottle, and apnea (breathing stop) may also occur.

Symptoms of GERD may include frequent regurgitation episodes, crying/irritability/pain, spasmodic backbends (flit arc attacks) in connection with meals, poor well-being (reduced growth and milestones) and refusal of the breast/bottle, respiratory symptoms (cough, wheezing) and apnea (stoppage of breathing).

You may also experience that the baby; does not want to lie down/does not sleep, gets food stuck in the throat, overeating, cries when burping/does not want to burp, baby colic, wet burps, wet hiccups, drools a lot, red eyes, earache, cries in the car seat and motor restlessness.

The more symptoms a baby has, the worse it is. But they can easily have reflux/silent reflux without all symptoms being present.

Reflux and sleep

We are experts in finding the cause(s) of sinusitis and otitis media.

As in the previously described sections, babies will not lie down when they have reflux/silent reflux and this means that they often do not want to sleep. In addition, they may have motor restlessness which makes it difficult for them to calm down and fall asleep. They will often lie with their heads pulled back, as this minimizes the backflow of milk. (See in relation to Positioning under the section good advice against reflux disease).

​Treatment of baby reflux

• Infants in good health do not need any treatment, even if they regurgitate a lot.
• In general, conservative measures should be tried before considering drug treatment. The drugs primarily used are Gaviscon, Nexium or Omeprazole.
• Gaviscon thickens and puts a lid on the stomach contents and inhibits reflux for a short time (a few hours). Note that it often causes constipation.
• Nexium and Omeprazole are acid pump inhibitors that reduce the production of stomach acid and make the regurgitation less acidic, thereby reducing the risk of acid damage. But this does not necessarily mean that the baby regurgitates less. For mild reflux, the medicine is used for 8 weeks. For more severe reflux, for 8-12 months.
  

  50% of infants will have an effect from conservative measures.