How do you know if your baby has reflux or colic?
How do you know if your baby has reflux or colic, or whether they’re just a ‘happy spiller’? Dietitian Jennifer Douglas outlines the symptoms and explains how you can help.
It’s quite normal for a baby to ‘spill’ after a milk feed; it’s their little body’s way of avoiding an uncomfortably full stomach. It can generate more washing and cleaning up than you’d like, but most of the time it’s nothing to worry about. In fact, the label ‘happy spiller’ is often given to babies who spill a lot yet are relatively content. However, it can be confusing trying to figure out whether your baby is actually a happy spiller or has a more serious condition with similar symptoms, such as reflux or colic.
WHY DO BABIES SPILL?
In babies and young children, the oesophageal sphincter (a ring of muscle which acts like a door between the stomach and the oesophagus) is underdeveloped, meaning milk and food can easily move or ‘spill’ up through it. This movement is called gastroesophageal reflux (GER or just ‘reflux’) and it’s usually nothing to be concerned about because most children outgrow it by the time they’re around 12 months old.
WHAT IS REFLUX?
I’ve talked about spilling, and another term for this is ‘normal reflux’. However, reflux can also be either ‘silent’ or ‘excessive’ – and neither are nice for your baby! Silent reflux is when the stomach contents and acid regurgitate back up into the oesophagus, causing a burning sensation and pain, but no actual vomiting (hence the name ‘silent’). The pain usually occurs 60-90 minutes after your baby has had a feed, and he may cry inconsolably and arch his back in pain. For a few babies, reflux gets so serious that it can affect their health. They may lose weight, develop lung problems or an inflamed oesophagus, and may even refuse to feed.
TIPS FOR MANAGING SPILLING AND REFLUX
✔ Small and frequent feeds/meals may reduce the overall volume going into your baby’s tummy.
✔ Change your breastfeeding position or try feeding lying down to see if you can improve how much your baby spills.
✔ If you have a fast let-down while breastfeeding, you could try expressing before latching your baby.
✔ If your baby is bottle-fed, then check the teat size: a larger size allows for fast milk flow and a small teat size means your baby has to suck really hard and could take in more air.
✔ Burp Baby frequently during feeding.
✔ Your baby should continue to sleep on their back but may benefit from a slightly elevated sleeping position. Elevate the head-end of the cot with a few books beneath the cot legs. Remember not to sleep your baby on a pillow until they’re more than 12 months old.
✔ Constipation can make reflux worse so keep a track of your baby’s bowel movements. If they are constipated you may need to consult your GP on how to manage this.
✔ Avoid using tight-fitting nappies that cause pressure on your baby’s abdomen and make them bring up their feed. This can especially be the case when using nappies that are too small or using cloth nappies with adjustable waistbands.
✔ Adding feed/formula thickener or Gaviscon to formula or breastmilk may help, but it is important to discuss using these with your GP first. It’s also important to add the thickener in small amounts as your baby may need it only slightly thicker to avoid reflux.
WHEN TO SEEK HELP
If none of the above strategies work, you should see your GP. It’s also important to seek help from your GP if your baby regularly projectile vomits, brings up green or yellow fluid, is not gaining weight, has breathing difficulties during and/or after feeding, or starts vomiting regularly after the age of six months.
Some of the signs of gastroesophageal reflux disease (GERD) in a baby could be:
✔ Unsettled, excess crying, poor sleep.
✔ Feeding difficulties and refusing to feed.
✔ Bringing up feed.
✔ Arching back during/after feeding.
✔ Post-feed wheezing and/or coughing overnight.
✔ Regular hiccups.
✔ Regular ear, nose and throat infections.
✔ Poor or excess weight gain.
SPILT MILK CLEAN-UP TIPS
Managing reflux on a day-to-day basis can come with some challenges – there’s likely to be more washing for a start! Here are some tips for dealing with that side of things:
✔ Use muslin cloths (which are quick to wash and dry) on your shoulder when burping your baby, and keep spares in your nappy bag.
✔ Carry several changes of clothes when you’re out and about.
✔ Use a Brolly Sheet on the cot/bed so you can take it off easily and wash it after baby has spilled.
✔ Use cotton/merino clothing that is easy to remove and wash rather than thick wool knits.
✔ Ensure the carseat has a washable cover that can be easily removed.
✔ Consider using a washable cover on your feeding chair or couch.
A DAIRY-FREE DIET
Your GP or specialist will advise you on how to manage GERD, but your baby may benefit from a two- to four-week trial of a dairy-free diet before anti-reflux medications are started. Cow’s milk protein intolerance is regularly found to be an underlying cause of GERD in infants, and guidelines from the Best Practice Advocacy Centre for New Zealand (BPAC) suggest that a dairy-free diet should be trialled before using anti-reflux medications.¹
Following a dairy-free diet can be very challenging so seeking help from a registered dietitian can help you do it properly. If you’re breastfeeding, this involves cutting out all the cow’s milk protein from your own diet. It’s important that you know how to identify which foods to avoid, how to read food labels and how to get the 1000mg of calcium you need daily for breastfeeding from dairy-free sources. To meet your calcium requirements for breastfeeding you’ll need at least three serves of calcium-fortified products, such as soy/almond/oat/rice milk which has at least 120mg of calcium per 100mls, calcium-fortified dairy-free cheese and dairy-free sauces that are made with calcium-fortified milks, along with leafy greens, tofu and nuts/seeds that contain some calcium.
You may need to add extra fat sources to your diet, such as nut butters, nuts and seeds, avocado and olive oil to help meet your breastfeeding energy demands.
If your child is on standard cow’s milk formula, then you may need to discuss altering the formula before starting on anti-reflux medications. Goat’s milk formula will not improve an underlying cow’s milk protein intolerance as the proteins are very similar to cow’s milk (and this is similar for other mammalian milks). If your child is over six months old, then you can trial soy formula as a dairy-free alternative to normal formula. If your child is under six months old, then they’ll need to trial a hydrolysed formula with a prescription from your GP or a registered dietitian.
If the dairy-free diet trial isn’t successful and your child has complications from gastroesophageal reflux, then you need to see your GP or specialist to discuss reflux medications. These can either be protein pump inhibitors (PPIs such as omeprazole) or histamine-2 receptor antagonists (H2Ras such as ranitidine). Neither of these should be prescribed unless you have trialled all of the above strategies and your infant has complications relating to reflux.
Once your baby is around six months, but not before four months, you may wish to introduce solid foods. For some infants, this can help with their reflux – but for others it may just produce colourful vomit! If you decide to introduce foods before six months, then smooth puréed foods should be introduced. The baby-led approach (offering cooked whole finger foods) after six months of age may be useful if your baby has lost trust in food or gets upset when you try to feed them with a spoon.
If your child requires a long-term dairy-free diet you’ll need to ensure they get adequate calories/protein for growth. Children avoiding whole food groups are at risk of slower growth and development, so it’s important they get support to ensure they are eating right. Talk to a dietitian about suitable foods for weaning your baby on to solids, how to avoid cow’s milk protein in foods, how to read labels, how to substitute for family foods, how to meet calcium requirements and how to manage the transition to daycare/school.
WHEN IS IT COLIC?
Colic is inconsolable crying for several hours in a row (usually in the late afternoon and evening), and which occurs in an otherwise healthy baby. It starts around two weeks of age and can continue until your baby is between four and six months old. Colic symptoms may be caused by underlying reflux, food allergy or other medical conditions, so do seek help from your GP or Plunket nurse. Many breastfeeding mothers have noted that colic episodes improve with a reduction in ‘windy’ vegetables; a small study carried out by Monash University found a reduced number of hours of crying in babies whose mothers followed a low FODMAP diet – low in fermentable carbohydrates, such as cauliflower, beans, wheat, milk, onion and garlic etc. However, more research in this area is needed before this is used as a regular management for colic.
SOME PRACTICAL TIPS TO HELP MANAGE A COLICKY BABY:
✔ Carry your baby in a baby carrier during the evening so they can continue to be held while you get on with everyday activities, such as attending to your other children or preparing food.
✔ Take regular breaks by passing baby to your partner and having time away from the crying.
✔ Eat a substantial afternoon tea so you have energy for the evening and to ensure good breastmilk production with regular evening feeding sessions.
✔ Get plenty of rest and sleep when you can, and let the household chores slide.
It can be a big challenge to have a baby with reflux and colic. Having regular time-out and asking for help from friends and family are supportive ways to get through. For both reflux and colic, it’s important that you also seek help from your GP and/or plunket nurse.
Jennifer Douglas is a Registered Dietitian who specialises in nutrition and food allergies and intolerances. She has more than 14 years’ experience working with families who she sees in her Dunedin clinic or via Skype. She also holds baby and family feeding seminars in Dunedin or via virtual link to parenting groups. Find her at jumpstartnutrition.co.nz.
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