Painful Infant Reflux/ Gastroesophageal Reflux Disease (GERD)

Reflux

  • Every baby has reflux. Every baby spits up.
  • Reflux is when food moves from the stomach backward into the esophagus (food tube).
  • For babies between birth and 6 months of life, reflux happens 20-30 times per day.
    • Most of the time, babies swallow it back down to the stomach before we ever see it.
      • This is called "silent reflux."
    • Other times it gets all the way out, and we definitely see it!
      • This is called "spit-up."
  • Every baby has reflux because the rubber band (sphincter) that's supposed to keep food from going backward is loose in babies.
    • It gets tighter and stronger as they approach 6 months.
  • Your baby's spit up changes all the time during the first 6 months of life, and just when you're getting used to the pattern, it will change again.
  • Our article about Spit Up is a must read for caregivers to help you understand what's normal, and when to be concerned.

Painful Reflux (GERD)

  • Every baby has reflux, but a small percentage of babies have painful reflux.
  • We recognize these babies because it hurts them to eat.
    • They show you they're hungry, but after a few sucks/gulps they pull away and cry because it hurts.
    • Once the baby calms and is offered more food, the same thing happens again.
  • Painful reflux isn't usually present at birth, but it can show up anytime in the first 6 months of life.
  • When it starts, painful reflux doesn't usually happen with every feed.
    • Over time the number of painful feeds per day increases.
  • Treatment is indicated when ~50% of the feeds per day are painful, because that frequency can prevent good weight gain, or even cause weight loss.
  • GERD is temporary.
    • Most babies outgrow GERD by 6 months of life.

Next Steps if You Suspect Your Infant Has GERD

  • If you think your baby is having painful eating, please let us know.
  • If painful eating is present >50% of the time, we will want to schedule a visit to discuss treatment.
  • Start a feeding journal that all caregivers can collaborate on, to track the frequency of painful feeds per day.
    • "Date/Time - Pain/No Pain"

Treatment

  • Treatment for GERD is a step-by-step, algorithmic approach.
  • At each step, we will explain the plan in detail, including follow-up schedule, as well as "next steps" if the current intervention is not successful.
  • We believe it's important for caregivers to be involved and understand the treatment plan, as well as the big picture, including "next steps."

Step One

  • The most common cause of GERD is a temporary inability to digest the following food proteins in the baby's diet:
    • Dairy (cow's milk)
    • Soy
    • Eggs (much less common)
  • These proteins can come from Mom's diet (via breastmilk), or from normal baby formula.
  • For breastfed babies, Step One is to remove the most likely culprits from Mom's Diet.
    • Dairy products (cow's milk)
      • See helpful link here for other hidden sources of dairy
      • Other animal milk products should be removed as well (e.g. goat milk)
    • Foods with soy as the first ingredient
      • Soy milk, tofu, edamame, soy-based meat alternatives
    • If there's no improvement after one week, we also remove the following:
      • All soy-containing foods (not just first ingredient soy)
        • See helpful link here for hidden sources of soy
      • Eggs
  • For formula-fed babies, we change to a formula that has already broken down (extensively hydrolyzed) those proteins.
    • "Partially-hydrolyzed" and "sensitive" formula types are not effective.
    • Extensively-hydrolyzed infant formula examples include:
      • Nutramigen (Enfamil)
      • Alimentum (Similac)
      • Nutramigen with Enflora LGG (Enfamil)
      • Pregestimil DHA and ARA (Enfamil)
      • Extensive HA (Gerber)
      • Pepticate (Nutricia)
  • For babies who eat breastmilk and formula, we make both of the changes above.

One Week Follow-up Visit

  • MP will schedule a follow up appointment one week after making these changes to assess how your baby is doing and determine the most appropriate next steps/potential additional changes.
  • After 1 week of the "Step One" changes, we expect and hope that your baby will be about 50% improved.
    • For example, if they used to show signs of GERD during 75% of their feeds, we expect them to only show signs of GERD during 25% of their feeds.
  • ≥50% improvement
    • Continue the Step One changes until the 6 month visit.
  • <50% improvement
    • Move on to "Step Two" described below.

Step Two

  • Continue Step One changes
  • Start medication that reduces the acid in your baby's stomach
    • Famotidine (i.e. Pepcid).
    • Your baby will take this medication twice a day
  • Schedule a follow-up visit for one week

One Week Follow-up Visit

  • Your MP provider will schedule another follow up visit one week after making these changes.
  • After 1 week of the "Step Two" changes, we expect and hope that your baby will be about 50% improved.
    • For example, if they used to show signs of GERD during 75% of their feeds, we expect them to only show signs of GERD during 25% of their feeds.
  • ≥50% improvement
    • Continue the Step One and Step Two changes until the 6 month visit.
  • <50% improvement
    • See "Step Three" below.

Step Three

  • Continue Step One and Step Two changes
  • Increase the medication dose
  • Schedule a follow-up visit for one week

One Week Follow-up Visit

  • ≥50% improvement
    • Continue Step One, Step Two, and Step Three changes until the 6 month visit.
  • <50% improvement
    • We will refer your baby to pediatric gastroenterologist (GERD experts) for additional guidance.
    • Trial of a different antacid medication (omeprazole, a.k.a. Prilosec) while waiting for appointment with gastroenterology.

Things to Keep in Mind

  • Please reach out to the MP team at ANY point during the process with further questions or concerns.
  • We may have to adjust your baby's medication dosage as they gain weight.
    • If you feel that they have "outgrown" their dose, please contact us for a follow-up visit.

FAQ

We started treatment and the painful eating is gone, but my baby is still spitting up a lot.

None of these intervention will impact how often or how much your baby spits up. They are expected to do one thing: decrease the frequency of feeds that are painful. This is accomplished by decreasing the amount of painful acid that's present in the reflux/spit up.

Why don't you begin by removing all the possible problem foods from Mom's diet from the start?

Dietary restriction is a lot to ask from a breastfeeding mother, so we want to remove the least number of foods required in order to get the desired result.

I accidentally ate something with soy at dinner, and now my baby is having painful eating again.

Don't worry, this happens a lot! Once you return to the dietary restriction that was working before, your baby's painful eating will go away much more quickly than it did when you first started.