Breastfeeding the Baby with Gastroesophageal Reflux
Damascus, Maryland, USA
From: NEW BEGINNINGS, Vol. 15 No. 6, November-December 1998, pp. 175-76
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
For most babies, spitting up is just part of a normal day's activities. "In a healthy baby," says LLL Medical Advisor Dr. Gregory White, "Spitting up is a laundry problem, not a medical problem." However, in an infant with the medical condition called gastroesophageal reflux (GER), spitting up may be frequent and painful. GER occurs when the muscle at the entrance to the stomach fails to keep the stomach contents in the stomach. The milk or food, along with acid from the stomach, backs up into the lower esophagus and irritates the tissues there. Adults recognize this feeling as heartburn. Babies just know that they're miserable. Some spit up. Others cry or act as if they are in pain. Physicians used to dismiss these symptoms as colic, something which they could not explain and parents just had to survive. Now they believe that at least some cases of unexplained, inconsolable crying may actually be reflux.
Most babies outgrow GER by their first birthday, and for many, symptoms begin to improve around six months of age, as they learn to sit up. Breastfeeding can and should continue when a baby has reflux. Research has shown that breastfed infants have fewer and less severe episodes of GER. Some breastfed babies with reflux may not even have any symptoms (Lawrence 1994).
Most physicians diagnose GER based on a parent's description of a baby's symptoms. GER shows itself in different ways in different babies and having one or more of the following symptoms may or may not mean a baby has GER. Parents and doctors have to look at the whole situation to decide what is bothering the baby and what should be done about it.
Symptoms of GER in an infant may include one or more of the following: frequent burping or hiccupping, frequent spitting up or non-projectile vomiting, frequent night waking, poor weight gain, difficulty swallowing, sudden or inconsolable crying, arching during feeding, constant nursing, or disinterest in nursing. Medical testing for reflux in a baby under a year old is rarely indicated unless the baby shows signs of poor growth, severe choking, or lung disease. Testing can involve barium swallow x- ray exam, endoscopy with biopsy, pH probe, and other invasive techniques. These tests should be used cautiously. They may interfere with breastfeeding and do not always provide conclusive results.
Breastfed babies seem to cope better with GER than artificially fed babies. During breastfeeding the motion of the baby's tongue triggers peristaltic waves along the gastrointestinal tract (Lawrence 1994). These muscular contractions help to move the food down into the stomach and on to the small intestine. Human milk digests more completely and almost twice as fast as formula. The less time the milk spends in the stomach, the less opportunity there is for it to back up into the esophagus. In addition, breastfed babies are generally fed in a more upright position than artificially fed babies, and gravity may help to keep the milk and gastric acid in the stomach where they belong.
Parenting an infant made unhappy by GER can be stressful. Mothers of babies who are hurting need support as they try to comfort their babies and take care of themselves. Continuing to breastfeed provides many benefits to the baby and the mother: improved health, development, and most importantly, a strong bond that can help get you both through this difficult time. Here are some things to try to reduce the baby's discomfort:
- Upright positioning. By keeping the baby in an upright position both during and after breastfeeding, gravity can help keep the milk from coming back up. Use a sling or front carrier to position the baby at breast level and nurse while standing or walking. Nurse lying down, side by side, with baby elevated on mother's arm. Try feeding in a recliner or reclining on pillows on a bed. Put baby chest to chest with mother, facing in to the breast, head slightly higher than the nipple.
- Thorough burping. See THE WOMANLY ART OF BREASTFEEDING, pg 58, for information about burping baby gently.
- Small, frequent feeds. One way to do this is to nurse on only one breast at each feeding. As the lactating breast never truly empties, the baby will be rewarded with a slower flow of milk that may soothe a burning throat, but not overfill his stomach. A strong rush of milk may cause the baby to gulp and swallow more air, which can trigger more spitting up.
Holding and comforting is important to a baby hurting from reflux. Babies who are upset and who are crying hard are more likely to experience episodes of reflux. A parent's loving arms really do make a difference. Thickening milk feeds with cereal is often suggested as a strategy to minimize reflux, on the theory that heavier food will stay down better. If a breastfeeding mother wanted to try this she could express her milk and feed it to her baby with a spoon after adding cereal. However, research has not proven this strategy to be helpful in relieving the problem. In a baby younger than six months, the cereal may replace rather than supplement human milk in the baby diet, and this can lead to a decrease in the mother's milk supply; cereal is not as nourishing as human milk. Also regurgitated solids are more irritating than regurgitated human milk. They might be aspirated into the baby's lungs causing pneumonia or the baby may develop an allergic reaction to the food.
Some babies with reflux may want to breastfeed frequently because the milk acts as a natural antacid and suckling itself can be soothing. However, if the baby overfills his stomach capacity, reflux symptoms can worsen. In this case, it may be helpful to limit nursings to one breast for a two to three hour period before switching to the other side. This way the milk flows more slowly.
Other babies with reflux quickly learn that pain follows eating so they refuse to nurse. These babies may benefit from techniques such as varying positions, nursing while baby is sleeping, eliminating distractions, or walking while nursing. Expressing before a feeding to start the milk flow before putting baby to breast may make nursing less frustrating for this baby and keep him from swallowing air when the milk lets down. Warm baths, skin-to-skin contact, and infant massage may help to calm a distraught baby.
It may be tempting to consider artificial feeding for a baby with reflux in hopes that the symptoms will improve. Mothers often worry that their milk is at fault. Remember that human milk is the best possible nutrition for babies. Experts knowledgeable about both GER and breastfeeding believe that changing to artificial formula makes the problem worse instead of better. In most cases, time and maturity will take care of reflux. In the meantime, mothers of babies with GER can reassure themselves that by breastfeeding they are giving their baby the best start in life.
This article was edited in May, 2004, to reflect the most up-to-date information available.
Lawrence, R. Breastfeeding: A Guide for the Medical Professional, 4th edition. St. Louis: Mosby. 1994.
Mohrbacher, N. and Stock. J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLL1, 1997.
Resources for Parents
Jones, S. Crying Babies, Sleepless Nights. Harvard Common Press, 1992.
Sears, W. THE FUSSY BABY. Schaumburg, Illinois: LLLI, 1985.
Sears, W and Sears, M. The Baby Book. Boston: Little, Brown, 1993.
For more information on GER, contact:
Pediatric / Adolescent Gastroesophageal Reflux Association (PAGER)
PO Box 486 Buckeystown, MD 21717-0486
Phone: (301) 601-9541
Web Site: http://www.reflux.org
Laura Barmby is the author of a new LLLI Booklet, Breastfeeding a Baby with Reflux (No 524-24, $2.50).