How To Wean A Baby With Reflux

What is reflux, and what other names is it known for?

Gastro-Oesophageal Reflux. It is likely one of the most common causes of concern for parents of infants/newborns. In simple terms, it is the passage of the stomach content into the oesophagus. The LES (lower oesophageal sphincter) is not yet competent in preventing that passage in young children. Signs can sometimes be hard to understand, as not in all cases you will see the feed coming out or reaching the mouth.

This is what is commonly called “Silent Reflux”.

GORD/GERD (depending on whether English or American English), or GastroOesophageal Reflux Disease, is when reflux gets more severe and treatment is needed. There are common behaviours that can be taken into account, to make that diagnosis, though all need to be put into context as not always it means the child has reflux.

So what are they?

• Back arching
• Unsettled when lying flat.
• Need to wind in an upright position for long periods.
• Need to fall asleep upright.
• Frequent hiccups (stimulation of phrenic nerve by acid in the oesophagus)
• Frequent feeding (feeding leads to release of endorphins, decreasing pain caused by acid reflux – if not treated, can lead to food refusal).

If we look at the incidence of this condition, it would be easier to understand the outcome.

• Usually begins before the infant is 8 weeks old
• It affects at least 40% of infants
• 65% of healthy 4 month olds regurgitate more than once a day.
• It may be frequent (5% of those affected have 6 or more episodes each day)
• Decreases with age: 5% of 10-12 month olds regurgitate daily
• It resolves in 90% of affected infants before they are 1 year old
• It might be associated with food allergy (cow’s milk more common)
• It can be related to overfeeding

Something to bear in mind is that a significant proportion of GOR in infants might be associated with a milk allergy:

• 204 infants (<1yr) with GOR
• 40% respond to cow’s milk exclusion (hydrolysate)
• Responders typically had other GI symptoms and atopic features (eczema)
• (Iacono et al. J Allergy Clin Immunol 1996; 97: 822-7)

Investigation and treatment

Do we always need to investigate and/or treat? Not at all. In reality, most cases just need conservative measures. Treatment is needed only when it becomes more severe and starts affecting the child.

The most common conditions that suggest investigations are:

• Failure to thrive
• Respiratory compromise
• Acute life-threatening events
• Oesophagitis (endoscopy needed to make a diagnosis)
• Feed refusal
• Haematemesis (vomiting blood)

If you are worried and see any of the symptoms described above, go to your GP, and he/she will address those issues and eventually refer to a Paediatrician, a Paediatric Allergist or a Dietitian.

If your child has significant symptoms and treatment is needed, what are the choices?

• Head elevation of 30 degrees (debatable)
• Omeprazole
• Ranitidine (now taken out of the market due to cancer associated fears)
• Prokinetics (help LES work better and increase gastric emptying)
• Domperidone
• Erythromycin

For severe cases:

• Naso Jejunal Tube feeding
• Fundoplication

If the reflux is associated with a delayed kind of allergy (what is known as non-IgE mediated), then the choice is dietary therapy, which a Paediatric Dietitian should guide, and eventually a Paediatric Allergist.

There is something essential to remember:

• Do not try a Lactose Free formula if there are worries of a milk allergy!
• Lactose is the sugar in milk, not a protein.

Do not try medication for colic, as evidence suggests they are of no use. Often, it is either coincidental improvement or even the placebo effect on parents, as they feel something is being done.

Where to start weaning a reflux baby

Is weaning that important, or can an infant carry on just breastfeeding or bottle feeding?

Well, if you want your child to grow better, and be healthy, then weaning is extremely important. And the main reason we need to think of is that a child doubles in size in their first year of life. The other stage in one’s life, with exponential growth, though not nearly as great, is the one associated with puberty. From the age of four to six months, both breastmilk and bottle milk no longer be enough for their nutritional needs. But the age at which weaning should be started is still a reason for many debates. Of course, there is still the aspect of allergy prevention in mind.

Unless your child is at risk of developing allergies, weaning should be started at 6 months of age, as per current recommendations.

So, when should you wean early to try to prevent the development of allergies?

Only when your child falls into one of these groups:

• Infants and young children with a family history of atopy are at high risk of developing allergic disease.
• Those with a personal history of atopy, particularly those with moderate-to-severe eczema, are also at increased risk of developing other atopic diseases, including food allergies.
• Infants who already have a food allergy.

If you look closely, there is no reference to reflux as being one of the reasons.

Weaning a reflux baby: does anything change?

The straight and easy answer is NO. Often I hear parents telling me they were told weaning early would help with reflux. And it seems the reasoning for this is that solids are thicker and heavier, so they are harder to “go up”. In reality, this does not happen. What will contribute to a decrease in reflux is the improved efficacy of something called the “lower oesophageal sphincter” (LES).

Allow me first to explain what a sphincter is. In simple terms, it is a bundle of circular muscles surrounding a passage, an opening or a tube. And we have plenty of them in our body.

In the LES case, it works like a tie knot, and it becomes more efficient as the core muscles (abdominals and so on) also become stronger. This will happen as the child starts walking and carries on for a few years more. Associated with this improvement in tone, we need to add the shear effect of gravity to the stomach contents.

Think of it this way:

• A child is flat – the stomach content is at the same level as the mouth, so the effort of coming out is minimal.
• The child is standing – the stomach content is much lower than the mouth. The taller they are, the more difficult it is for food to reach the mouth.

Therefore, the general advice of starting with fruits and vegetables, one each time and on different days, still holds on.

After that, comes the natural progression to potentially more allergenic food to increase prevention against the development of allergies. For those, current advice says to start with egg and peanut first. Wheat, sesame, fish, meat and tree nuts should be introduced straight after.

So, the bottom line is:

• Seek help if your child has reflux.
• Treat reflux, according to the advice you have received.
• Start weaning at six months, except if your child is at higher risk of developing food allergies.
• Do not start weaning early, just because of reflux.

References

1.      LEAP Study (Lack et al., Dec06 – May09)
2.      EAT Study (Lack and al., Jan08 – Aug15)
3.      LEAP-ON Study (Lack et al., May11 – May14)
4.      Historical Overview of Transitional Feeding Recommendations and Vegetable Feeding Practices for Infants and Young Children: Nutr Today. 2016 Jan; 51(1): 7–13.
5.      American Academy of Pediatrics Committee on Nutrition. In:Pediatric Nutrition Handbook. (editions from 1979 to 2014)
6.      Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune Disease: A Systematic Review and Meta-analysis. JAMA. 2016;316(11):1181-1192. doi:10.1001/jama.2016.12623
7.      BSACI: Early feeding guidance for Health Care Practitioners.