This article follows on from our previous one, Infant Reflux – What it is and how to recognise the signs! It looks at the treatment and management of the various types of reflux. As Infant Reflux can often be a difficult condition to manage effectively, we advise you to always follow the guidance of your Medical Practitioner with regard to treatment.
Management of Positional Reflux
This is the mildest form of reflux and in most cases will resolve with a few simple measures.
- Keep baby in an upright position if possible during feeds and for at least 30 minutes afterwards.
- Gently wind baby frequently during the feed.
- Do not over feed baby.
- Gentle movement in a sling or buggy may help so long as baby remains in the upright position.
- Elevate the head of the cot so that baby is sleeping at a 30 degree tilt.
- If possible, never lie baby flatter than a 30 degree angle, even when changing a nappy.
- Avoid exposure to Tobacco smoke as it causes irritability.
- Avoid tight nappies or clothing, especially around the abdomen
Management of Silent Reflux
You should use all the above techniques for a baby diagnosed with silent reflux in addition to;
- Gaviscon or Carobel are Antacids that can be used to thicken formula feeds. The reason for thickening the formula is to help keep it in the stomach. You should always follow the dosage guidelines on the packet but you can adjust the amount of antacid downwards depending on your baby’s needs.
- When using an antacid you should be aware that it may cause constipation. If this happens you can give baby some drinks of cool boiled water between feeds or/and you could reduce the amount of antacid in the feed. If this does not resolve the constipation you should discontinue the antacid and see your GP.
- A pre-thickened formula feed is another option. These feeds have a built in thickener that starts to work when the formula is made up. You should follow the directions carefully as some formulas have very specific instructions for preparation. You will also find that you may need to move to a faster flowing teat so that baby can take the new formula easily. You should never add another thickener to an already pre-thickened formula.
- Babies with Silent Reflux very often fall into the category of Acid Reflux and may also require medication as discussed below.
- Breast Fed Babies may also have silent reflux. It is certainly possible to treat a breast fed baby but it is more of a challenge. When giving an antacid you should use a little expressed milk and add the antacid to this. Give it before the breast feed while baby is hungry.
Management of Acid Reflux
You should look at all the above suggestions for a baby diagnosed with Acid Reflux in addition to;
Ranitidine (Zantac) – Prescription Only.
Ranitidine reduces the amount of acid in the stomach, which reduces the symptoms of acid reflux. Zantac comes in a liquid form for babies. Once opened, Zantac should be kept in the fridge and discarded after 4 weeks. The dosage of Zantac is based on baby’s weight and should therefore be reviewed regularly with your GP or Pharmacist. Zantac can taste quite sour so giving it with a little gripe water may help if baby does not like the taste. Zantac can be given by syringe or in a bottle teat. It can be given over 2 or 3 doses a day.
Omeprazole (Losec Mups) – Prescription Only.
Omeprazole is a Protein Pump Inhibitor (PPI) and blocks the production of acid in the stomach. Dosage is based on baby’s weight and should therefore be reviewed regularly with your Paediatrician or GP. If giving Losec twice a day, the evening dose should be given before 5.30pm as there is very little acid produced from 9pm till 2am (resting phase) and a PPI can only turn off a pump that is turned on. During the resting phase there are very few Acid Pumps turned on and so most of any dose given during this time will be of no use. From 2am to 7am there is an acid dump where the stomach produces extra acid. If your baby is most unsettled at night, then you could give the 2nd dose of Losec at 12.30 to 1.30am.
Losec cannot be crushed and given with food. It must be dissolved in a little cold water and given in a syringe or off a spoon. For older babies the tablet can be dissolved in a little applesauce. It is the beads you see after dissolving the tablet that contain the active ingredient. Losec should be given on an empty stomach and within ½ an hour of dissolving the tablet. A Losec tablet can be split in half using a Splitter which your Pharmacist can supply if the dosage requires this.
Management of Reflux Secondary to Cow’s Milk Protein Allergy
Although it’s important to follow the steps on the treatment ladder, it is also essential to be aware that when baby’s reflux is not responding to treatment, the possibility of the reflux being secondary to a CMPA must be considered. A study done in Australia in 2008 stated that up to 40% of babies presenting with symptoms of GORD were diagnosed with a Cow’s Milk Protein Allergy. 3 If baby has any of the dermatological or respiratory symptoms associated with CMPA, it should be considered even sooner. The reflux symptoms will be slow to improve while baby is still taking cow’s milk protein. And in fact, if the CMPA is treated early on, the symptoms improve and you may not need to travel too far up the treatment ladder! As with all the digestive disorders, you may find that you will be treating more than one condition at a time but, with information and support, that’s very possible! Read this article for more information on CMPA.
Formulas for Reflux
|Aptamil||Aptamil Anti-Reflux||This feed is thickened with carob bean gum. It has a thicker consistency than normal feeds and a single hole fast flow teat should be used. The feed should be made with hand hot previously boiled and cooled water. This feed can be used up to 12 months old.|
|Cow & Gate||C & G Anti-Reflux||This feed is thickened with carob bean gum. It has a thicker consistency than normal feeds and a single hole fast flow teat should be used. The feed should be made with hand hot previously boiled and cooled water. This feed can be used up to 12 months old.|
|SMA||SMA Staydown||This formula should be made up with chilled previously boiled and then cooled water. The feed contains a digestible natural corn starch to help keep the feed in baby’s tummy. It has a normal consistency and no change in teat is required. The feed is thickened on contact with the acid in the stomach. This feed can be used up to 18 months old and can be mixed with food for weaning.|
|Nutramigen||Enfamil AR||This is a pre thickened formula for babies with Reflux. The feed is a normal consistency and can be given via a regular teat. It thickens on contact with Gastric acid.|
How can Cranial Osteopathy help a baby with Reflux?
Cranial Osteopathy, in a very gentle way, encourages the body’s tissues to release any tension and increases tissue flexibility. Reflux in my opinion challenges a number of key areas that support digestion. Firstly, the intestinal tract can become bloated and retain gas for longer periods. Secondly, the arching and extending associated with reflux can tension the breathing diaphragm as the baby is trying to ease their discomfort. Thirdly, as arching of the back persists, the neck musculature can also tension. Treatment applied to these key areas allows a gentle releasing of tension and lengthening of these tissues. This creates a more comfortable feeding process for the baby and eases the tissues supporting digestion.
Reflux Survival Strategies.
Infant Reflux is a condition we see every day at the clinic. What our years of experience has shown us is that there are many different levels of Reflux and no one solution that works for all babies. Some babies have a positional reflux, where keeping the baby propped up can alleviate the symptoms. Other babies have a mild acid reflux where a change of formula and perhaps an antacid will be the answer. And then there are the babies with severe acid reflux! This is a completely different story. Caring for these babies causes a significant amount of stress. Treatment can include formula changes, medication and constant revisions, sometimes with very little success! Every day can be a challenge. With this in mind we have listed a few tips for these parents specifically.
- Don’t expect to have all the answers at the beginning as it’s a really steep learning curve.
- There are no right or wrong answers for babies with reflux, as what works for one baby may not work on another. Take advice from your medical practitioner and ask as many questions as you need to understand your baby’s condition. It really is trial and error until you find something that works for your baby.
- Accept you are doing your best and focus on what’s going right rather than what you feel is going wrong.
- Believe in yourself and trust your instincts. Reflux is a medical condition; it’s not in your head!
- You can drive yourself crazy trying to figure out why one day is better or worse than another! The simple fact is that reflux can be cyclic and some days may just be worse than others for reasons you may never know.
- Look after yourself and accept any offers of help. Please ask for help if you need it. Talk to someone – talking to someone can often relieve the strain and often helps you to see what you can do about the problem.
- Many parents have reported that reflux can flare up when a baby is stressed or sick. Hot weather, teething, over-tiredness all can affect baby. However, knowing this can help as any changes make more sense.
- Recognise that there will be times when you’re more able to cope, and more positive, while other times you will feel quite low and overwhelmed. This is normal. Take each day as it comes and just maybe it helps to know that things will get better, no matter how hard it is right now. Remember though, that if feel you’re not coping, please ask for help and seek medical guidance. Your baby needs you to be well too.
Reflux Symptom Checker
|Symptom||Tick if your baby has this symptom|
|Crying and irritability for longer than 3 hours|
|Regurgitation of milk|
|Regurgitation of clear fluid|
|Arching when feeding or after feeding|
|Wheezing on an ongoing basis|
|Baby continually swallowing|
|Baby comfort feeds|
|Baby is in constant motion|
|White milk can be seen on the tongue|
|Baby sweats excessively|
|Baby refuses feeds|
|Baby has a cough|
|Baby is not gaining weight|
Use this chart to document your child’s symptoms. When you go to see your Health Professional, bring your Symptom Checker with you as this will be helpful in assisting them to make a diagnosis. It also ensures that you will remember to tell your Health Professional everything!
Frank Kelleher Paediatric Osteopath
The Children’s Clinic, Cork.
Tel: 021 4348918