GERD and the Breastfed Baby
Newark NY USA
From: LEAVEN, Vol. 39 No. 1, February-March 2003, pp. 12-13.
GERD is an acronym for gastroesophogeal reflux disease. Reflux occurs when stomach contents are spontaneously returned into the esophagus. The main barrier to reflux is the lower esophageal sphincter (LES). This is a band of voluntary muscle fibers within the esophagus where it travels through the diaphragm from the chest cavity into the abdominal cavity. Normally, there is enough pressure within this area of the esophagus to prevent gastric contents from being regurgitated from the stomach.
There are various reasons why the LES stops being able to prevent reflux. An overfilling of the stomach or increased gastric acid can overcome the LES. Many young babies have periods when the LES relaxes, which allows reflux to occur. Forcibly inhaling or exhaling can result in pressure changes that encourage reflux. This type of breathing is often seen with cystic fibrosis, respiratory infections, hiccups, and tracheomalacia (an abnormality of the trachea which causes it to be unstable and prone to collapse). It is also a symptom of bronchopulmonary dysplasia, which is a chronic pulmonary disease that can develop in babies who have been placed on ventilators.
Nasogastric tubes that are often used for feeding very premature or sick babies can decrease LES pressure and also act as a pathway for reflux. In fact, premature babies are generally more at risk for reflux, as are babies who are fed formula rather than human milk. Food allergies are also thought to play a role in some cases of GERD. In babies with hiatal hernias, the entire LES and a portion of the stomach protrude upward through the diaphragm and into the chest cavity, thus predisposing them to GERD.
The symptoms of GERD vary from vomiting to breathing difficulties. A questionnaire that was developed to help clinicians diagnose this condition (Orenstein et al 1996) revealed the following behaviors to be highly indicative of GERD: spitting up more than three times a day, spitting up more than a tablespoon, pain associated with vomiting, crying after feedings, crying for more than three hours a day, back arching and apnea (a temporary suspension of breathing), or cyanosis (a bluish-gray discoloration of the skin caused by lack of oxygen).
Babies may get into a pattern of frequent, short feeds as they go on and off the breast in an attempt to relieve the pain, or they may begin to reject feeding entirely. The painful burning abdominal sensation that adults in the USA know as heartburn, or pyrosis, causes a baby to fuss and cry usually within the hour after feeding. This can also cause frequent night waking. When stomach contents irritate the trachea or are actually aspirated (inhaled) into the lungs, then choking, apnea, cyanosis or pneumonia can occur (Orenstein and Orenstein 1988.) An infant who is merely spitting up frequently, but is otherwise content and gaining weight, most likely presents only a laundry problem. A baby who is in pain, not gaining, or not breathing properly is showing signs of an illness that must be properly diagnosed and treated.
Although there are some specific tests for GERD, including swallow tests, pH probes, and endoscopy (visual inspection of the esophagus by an optical instrument introduced within a tube), these are invasive and stressful for babies and often give inconclusive results. Therefore, many diagnoses are made by observing symptoms. Doctors also need to rule out conditions such as pyloric stenosis and metabolic dysfunctions, which can also cause vomiting and failure to thrive. (Editor’s Note: Please refer to the Leader’s Handbook for the scope and limits of the Leader’s role; as Leaders, we do not attempt to diagnose, but as necessary we may encourage a mother to seek advice from the appropriate health care professional. This article is intended to enlighten the reader, not prepare the reader to diagnose.)
In many cases, the baby’s relaxed LES tightens up as he matures and reflux subsides as a function of time. Overfeeding due to an overabundant milk supply or too forceful milk-ejection reflex can result in vomiting and discomfort while feeding. Proper breastfeeding management in these situations will often lead to a rapid decrease in symptoms as mother’s milk supply lessens to match her baby’s needs (Jozwiak 1995).
Breastfeeding itself is a treatment for GERD—doctors often recommend frequent, small feeds to promote gastric motility and emptying. Positioning is a standard treatment for GERD no matter what the cause (Orenstein and Whitington 1983). Babies need to be maintained in a more upright posture, both during and after feeds. It is recommended that the baby be held at a 45-60 degree angle while breastfeeding and that horizontal feeding be avoided entirely. Between feeds, baby can be held upright through the use of slings, soft baby carriers, or rigid carriers. However, baby should not be allowed to slouch, so care must be taken and bolsters may be needed to maintain baby in the proper position. Lying prone at an angle, such as on someone’s chest also seems to work well.
Sucking on an “empty” breast or even a pacifier helps by generating saliva (which neutralizes acid) and promoting peristalsis (the involuntary, wave-like motion in the GI tract that moves food along) that helps the stomach to empty more quickly. Formula stays in the stomach longer and can contribute to GERD (Heacock 1992). Since several studies have shown a strong link between GERD and cow’s milk allergy (Iacono et al 1996), diet management can be effective in this disease. Other common offenders are soy, eggs, and wheat. A two-week elimination of all dairy products from mother’s diet often produces noticeable improvement in a baby suffering from cow’s milk allergy. Too much caffeine consumed by the baby’s mother (which relaxes the LES) can cause a problem for some babies, as can exposure to cigarette smoke (Alaswad et al 1996).
Medications may be used in conjunction with other treatments. These include drugs that may counteract stomach acids, decrease the production of acids, promote gastric motility (movement of food out of the stomach and into the intestines), or increase LES tone.
Thickened feedings are suggested by many doctors. However, thickened feedings do not always work (Bailey et al 1987), can interfere with breastfeeding, and may increase the risk of food allergies. Some studies have shown that thickened feeds can have an adverse effect on growth in some babies and increase the risk of respiratory involvement (Orenstein et al 1992). Because thickened feeds remain in the stomach longer, they may actually cause more reflux. For these reasons, mothers should consider their options very carefully before deciding to use thickened feeds. If a mother does want to try this, she can use her expressed milk thickened with cereal and offer it with a spoon before regular feedings at the breast. Surgery on the LES is a rarely used treatment except in the most extreme and unresponsive cases.
Studies have shown that formula-fed babies are more likely to exhibit symptoms of GERD than are breastfed infants. Weaning from the breast should not be regarded as a good solution for GERD. Non-thriving babies should be evaluated for underlying illness. In most cases, GERD can be handled through proper breastfeeding management, positioning, mother’s diet, and education. When these steps do not bring about relief, more extensive testing and other treatment options may need to be explored.
Alaswad, B. et al. Environmental tobacco smoke exposure and gastroesophageal reflux in infants with apparent life-threatening events. J Okla State Med Assoc 1996; 7(89):233-7.
Bailey, D.J. et al. Lack of efficacy of thickened feeding as a treatment for gastroesophageal reflux. Journal of Pediatrics 1987; 110:187-89.
Cavataio F. et al. Clinical and pH-metric characteristics of gastro-esophageal reflux secondary to cows’ milk protein allergy. Arch Dis Child 1996 75(1):51-6.
Feranchak, A.P. et al. Behaviors associated with onset of gastroesophageal reflux episodes in infants: prospective study using split-screen video and pH probe. Clinical Pediatrics 1994; 33:654-662.
Heacock, H.J. Influence of breast vs. formula milk in physiologic gastroesophageal reflux in health newborn infants. J Pediatr Gastroenterol Nutr 1992; 14(1):41-6.
Iacono, G. et al. Gastroesophageal reflux and cow’s milk allergy in infants: a prospective study. J Allergy Clin Immunol 1996; 97(3):822-7.
Jozwiak, M. Overactive let-down: consequences and treatments. LEAVEN Sept-Oct 1995; 31(5):71-72.
Orenstein, S.R. et al. Thickened feedings as a cause of increased coughing when used as therapy for gastroesophageal reflux in infants. Journal of Pediatrics 1992; 121:913-915.
Orenstein, S.R. Gastroesophageal reflux. Current Problems in Pediatrics May-June 1991; 193-242.
Orenstein, S.R. and Orenstein, D.M. Gastroesophageal reflux and respiratory disease in children. Journal of Pediatrics 1998; 12:847-858.
Orenstein, S.R. et al. Reflux symptoms in 100 normal infants: diagnostic validity of the infant gastroesophageal reflux questionnaire. Clinical Pediatrics 1996; 35:607-614.
Orenstein, S.R. and Whitington, P.F. Positioning for the prevention of infant gastroesophageal reflux. Journal of Pediatrics 1983; 103:534-37.
Wolf, L. and Glass, R. Feeding and Swallowing Disorders in Infancy: Assessment and Management. Therapy Skill Builders, 1992
Breastfeeding the Baby with Reflux (pamphlet), La Leche League International
Available from LLLI, No. 524-24, $2.50
Breastfeeding Answer Book, Third Edition, La Leche League International
Available from LLLI, No. 1260-12, $68.00
Gaining and Growing-Assessing Nutritional Care of Preterm Infants: http://staff.washington.edu/growing/Feed/GER.htm
Sharon Knorr is a LLL Leader and Assistant Area Professional Liaison in upstate New York, USA. She is also a lactation consultant in private practice and in a local hospital. Sharon has two children (Joshua, 24; and Rachel, 21) and lives with her husband, Butch, in Newark, New York, USA. She has suffered from GERD for many years and hopes that this article will help babies to avoid some of her own unpleasant experiences with this condition.