The Great Baby Reflux Epidemic (or not….)
How many people do you know whose baby has, or had, reflux? A lot I’d imagine.
Reflux medications such as infant Gaviscon, Losec, Omeprazole, Domperidone, Nexium and Ranitidine are all too common place in homes with a baby. Ditto too special formula milks such as Nutramigen and Neocate.
It seems that everyone you meet either knows, or had a baby with reflux. Yet nobody really seems bothered by this. Nobody questions the gross number of babies afflicted with this disorder. Nobody questions the ‘experts’ who make their living from cashing in on specialising in infant reflux. I, however, am sick of it all.
Baby reflux is grossly over-diagnosed. Thousands and thousands of babies are being subjected to a chemical cocktail of medications and artificial milk needlessly. These medications do not come without risks and side effects – including a restricted level of calcium absorption, gastric polyps, constipation and stomach distension. For babies with genuine GERD/GORD the risks of prescribing are far outweighed by the benefits – in many cases lifechanging – that they bring. For most however the risks of these medications are not considered and it is prescribed without much more than a 5 minute chat with a GP. Diagnosing a baby with reflux appears to be an easy way out for GPs and Paediatricians, certainly the diagnosis is often not based on anything more than opinion.
Recent estimates suggest that around a quarter of all young babies will be diagnosed with reflux, I would go so far as to say it is higher than that. Much higher. This should raise alarm bells. What is even more alarming is that between 1999 and 2004 there was a sevenfold increase in the rate of prescription of infant reflux medication. I can’t even begin to imagine what the increase has been in the last ten years, but my guess is around tenfold. What has happened to our babies during the 21st century? Why are so many more suffering from reflux? I don’t think they are. I think it has become a social trend, awareness has raised massively, real problems (that aren’t reflux – more on this later) are being missed and – those with real issues aside – many parents are looking for medical explanations for their newborn’s perfectly normal behaviour (more on this later).
Dr. Eric Hassall, a Paediatric Gastroenterologist in San Francisco says: “fed by advertising and misinformation on the Internet, parent blogs have increasingly promoted the ”’my-baby-has-acid-reflux-and-needs-drugs’ concept. Parents, concerned by their infant’s symptoms of apparent suffering take their concern to doctors, who very frequently comply and prescribe acid-suppressing medications for symptoms and signs that in most cases are not GERD. GERD-mania is in full cry, so to speak.” Dr. Hassall goes on to say “We are medicalizing normality,” – I couldn’t agree more. As with sleep (see this post) we have a tendency to pathologise our baby’s behaviour when we don’t understand it, or it doesn’t fit in with our lifestyle. In many cases newborns with reflux are healthy newborns, acting just as newborns do. Not newborns suffering from reflux.
As Dr. Hassall says in his 2012 article (with reference to the gross increase of reflux medication prescription over the past decade) in the Journal of Pediatrics: “somehow the diagnosis of GERD has been missed over the past several decades or has recently become a major scourge of infants in the developed world, with acid suppressing drugs becoming a new essential food group in their own right. This change in practice has come about for several reasons, none based in medical science. There is, however, data to show that this practice does not serve our patients.”
He goes on to say: “Two phenomena have long been observed in otherwise healthy, thriving infants. First, many of them spit up on a daily basis—some 40% to 70%. The developing, rapidly-growing infant takes in feeding volumes that on a per-kg basis are huge compared with older children or adults…some of the large volume intake simply overflows upward, or sometimes “spills” out through the mouth. This has long been recognized as physiologic reflux not reflux disease [ie, not GERD]), and it is self-resolving in approximately 95% of infants by 12 to 15 months of age. Second, many infants are irritable or have “unexplained crying,” sometimes also referred to as “infant colic,” especially in the first 3 or 4 months of life. Spitting up and crying are common; in most infants…… However, increasingly, crying and spitting up have become conflated into a diagnosis of GERD…The largest randomized, controlled study to date in infants showed that for symptoms purported to be those of GERD, a PPI was no better than placebo….With increasingly less time to evaluate patients, rather than take on the more time-consuming history, discussion, and approaches, including behavioral and dietary, that are required around the evaluation of unexplained crying, and not without parental pressure to “do something,” doctors have taken to a quicker approach: prescribing.”
Research in 2013 has highlighted the worrying public trend for parents to want to medicate their babies for reflux. A trend that is heightened even more when GPs indicate that the baby may have reflux. With reference to the study, Professor Laura Scherer at the University of Missouri commented that “the growing digestive systems of an infant can be finicky and cause the child to regurgitate. The discomfort can cause the infant to cry, but it is not necessarily a disease. Parents can learn from this study that a disease label can make them want medication for their child, regardless of whether the drugs are effective or not. Parents should follow doctors’ advice, which sometimes means accepting a doctor’s explanation of why an infant’s crying and vomiting may be normal….. In addition, the long-term side effects of the medication frequently prescribed to children diagnosed with GERD have not been fully studied.”
So if it’s not GORD – or GERD if you’re in the USA – (infant reflux), then what IS wrong with the babies?
There is no one single answer to this question. The likely answer is “a number of different things”, these include:
1. They do actually have GORD.
This is the rarest of all the explanations and by far the least likely. It is however a reality for some and sadly those who need testing, diagnosing and treating the most are often the last to get it. I believe this is because the condition is trivialised so much by the seemingly enormous numbers of babies presumed to suffer from it. Those babies who are genuinely severely affected often face lengthy battles to get proper treatment.
Gastroesophogeal Reflux Disease is a fairly rare disease that affects the lower oesophageal sphincter, or LOS (basically a ring of muscle situated between the stomach and oesophagus that makes sure that what goes down, doesn’t come up). The LOS usually opens to let food down and then closes once it has passed. In GORD it is too weak or doesn’t close properly and the stomach contents, including acid, bile and food, flow back up into the oesophagus.
Symptoms are fairly obvious – think exorcist style projectile vomiting (not just normal baby ‘spit up’), uncontrollable crying, a ‘smoker’s cough’ or hoarse cry, lack of weight gain and foul smelling breathe. Sometimes the projectile vomiting is not present, in this case in babies it would be known as ‘silent reflux’.
Diagnosis of GORD should (but sadly often doesn’t) involve pH monitoring of the oesophagus, endoscopy and barium swallow and x-ray.
I can’t highlight enough that this is a rare disease, yes it exists, but not in the sheer amounts that we see today.
2. They have normal developmental Gastro-Oesophageal Reflux – or ‘normal reflux’.
To a certain extent almost every baby experiences reflux at some point. This is a perfectly normal developmental situation in healthy babies that highlights nothing more than their immature physiology. Most babies will experience episodes of reflux where they will ‘spit up’ their milk – either through their mouth or nose – or often both. This is a perfectly normal situation that the baby will grow out of usually over a couple of months, or at least by the time they reach 12 months of age. Normal reflux does not need any treatment or medication.
3. They have Colic.
Colic is a catch all term used to describe a baby who cries an awful lot but with no apparent reason for the crying and little that helps to soothe the tears, but it is not a specific disease or disorder. When we speak about “diagnosing colic” what we really mean is “I have no idea why this baby is so unhappy, so we will label the crying ‘colic’.”
The word derives from ‘Kolikos’ – a Greek term associated with the colon. When used relating to an organ of the body the term ‘Colic’ is used to describe a sudden pain which starts and stops abruptly, for instance renal (kidney) colic (usually caused by kidney stones), biliary colic (stemming from the bile duct and usually related to gallstones). You may have also heard of equine colic which is a serious condition in horses caused by a serious gastrointestinal problem. In all of these cases there is a very real physical cause for the colic – or pain, however in infantile/baby colic the cause is unknown and we do not even know that the baby definitely is crying because they are in pain.
Morris Wessel came up with his idea of ‘the rule of 3s’ in the 1970s (now know as ‘The Wessel Criteria) – that is a baby who fits the Wessel criteria to be diagnosed with colic is one who “cries for more than 3 hours a day, for more than 3 days a week, for over 3 weeks.” The Wessel criteria is now the one most commonly used in medical circles for diagnosing infantile colic and the criteria used for most research into baby colic. Around 1 in 6 babies will fit the Wessel criteria for a dianosis of colic. The real causes of colic however are likely due to numerous other issues including:
Lactose intolerance and Cows milk protein allergy
Tongue tie (more on this later)
Breastfeeding latch problems/oversupply issues (more on this later)
Cranial compression/residual birth trauma (see THIS article:)
Parental anxiety/stress
Misunderstanding of the needs of babies, including premature/overlong separation of baby from parent
Constipation and a lack of friendly bacteria in the gut and possibly an overgrowth of ‘bad’ bacteria in the gut
Having an immature nervous system and over-stimulation from the external world.
I feel it is also important to point out here that very young babies will almost always draw their legs up to the tummies, with their knees on their chest when they cry or feel scared, this is a normal reflex response and NOT a symptom of pain. Similarly they will often go bright red when they cry and their tummy will feel hard – this is due to muscular tension from the crying, again NOT pain.
4. Tongue Tie and Breastfeeding Latch Issues
In my opinion this is one of the top two causes of what people call ‘reflux’. In tongue tie the baby’s tongue is held too tightly to the base of their mouth by a short frenulum. This can either be visible if it is anterior (often the baby will have a heart-shaped tongue), however it can also be invisible to all but the highly trained (and here I mean lactation consultants – most definitely not GPs, health visitors, paediatricians and most midwives – who will have no idea what to look for) when it is situated at the back of the tongue (what is known as a posterior tongue tie). In addition a baby may also be suffering with a lip tie.
All of these can hugely effect feeding, weight gain, sleep and the baby’s behaviour. Common symptoms include: feeding difficulties (tongue tie can still affect babies who bottle feed), getting frustrated at the breast or bottle, disrupted sleep, poor weight gain, prolonged crying, sore nipples if the mother is breastfeeding, digestive disturbances (including vomiting) and a baby who doesn’t seem satiated after a feed (often because they get too tired from the effort and fall asleep before they are full).
To anybody reading this who thinks their baby has reflux, please – I urge you, contact a Lactation Consultant BEFORE you visit your GP, paediatrician or health visitor.
5. Not Understanding the Normal Needs of Young Babies.
This is the latter half of my “it’s not really reflux – it’s this” top two. Small babies need almost constant physical contact. They need to be held and carried (when they are asleep as well as awake). They are not meant to be sleep trained, taught to self soothe (read my article here for what happens when you do) or put down to get themselves to sleep. They need us. When they don’t get us they cry, lots and they are often sick, lots. Plus they don’t sleep (see the next point for more on this). If your baby is 12 weeks or less, read this article to learn more about their needs and how you can best meet them.
6. Incorrect Expectations of Babies.
Young babies don’t sleep. Actually even older babies don’t sleep much either. They wake often, often every 30-45minutes, they aren’t happy sleeping alone, they wake when you put them in a crib or cot, they wake early in the morning, they feed many, many times during the night. This is all normal. Even when you hold them in a sling for naps or bedshare at night they still wake lots.
Babies have tiny tummies, they need to feed lots and often their immature physiology will mean they spit up lots and you’ll drench more than a few muslins with baby sick.
Babies don’t much like being placed on their back either, despite this being by far the best way for them to sleep in terms of safety (note – I am NOT advocating anyone put their baby down on their front – ever, it’s dangerous), most babies are happier to lay on their front. This isn’t indicative of the dreaded reflux.
What we expect of baby’s sleep is quite frankly ridiculous. Babies don’t sleep much, babies cry lots (it’s how they communicate with us!). If parents weren’t deluged with so much inaccurate advice from experts, friends and relatives about babycare things would be much easier! and I’m pretty sure there would be a whole lot less reflux diagnosed. What makes the whole thing worse is that as a society our expectations of babies doesn’t tend to match our lifestyle. See this article for more. This absolutely doesn’t mean that a quarter of all babies have a medical disorder though. In most cases we are pathologising normal baby behaviour because as a society we are unable to adjust our lifestyle to meet their needs. Parents need more support in order to do the very important job that they do, they just don’t get enough now.
I for one am ecstatic about the new NICE guidance that advises doctors to use infant reflux medication more sparely. Despite headline grabbing articles stating how difficult it will be for parents to get reflux medication for their babies. Bring it on I say – maybe then these parents will actually get to find out what’s REALLY wrong with their baby and will receive the proper care, support and treatment that they – and their babies – deserve.
Sarah
