The Truth About RefluxKate Tuttle
“After months of smelling like curdled milk, I knew something had to be done,” says Jane, a Midwestern mother of two sons. Her first had nursed and gained well, a fat, happy baby. But her second, also breastfed, never seemed to gain weight and spit up after every feeding. To cope with the baby’s constant spitting up, Jane and her husband tried the solutions most parents do: “He used to sleep in his car seat by the bed so he could keep his food down. I tried simethicone, but that didn’t work.”
So what did? Time. “He eventually grew out of it at about six to eight months,” Jane says, “but he still seems to have a somewhat sensitive stomach.”
Her story is a familiar one. Gastro-esophageal reflux, or GER, is among the most commonly diagnosed health problems in babies, and the condition has spawned a growing industry in products and medications intended to cure or at least alleviate the symptoms. Faced with babies who spit up seemingly constantly, parents are moved to buy hammock sleepers, positioning wedges, and a medicine cabinet full of drugs, from gas-absorbers like simethicone to proton pump inhibitors like prevacid. But do they work? And is GER a real problem for most babies who receive the diagnosis, or a relabeling of a physiologically normal process that children outgrow with no ill effects?
Dr. Alice Newton, a pediatrician at a suburban practice outside Boston, sees a lot of babies with reflux. “I would say at least 40% of babies have reflux to some extent, but not all of those babies have symptoms so severe they need to be treated,” she says. “Some babies spit up a little bit, feed just fine, aren’t irritable, and don’t have the symptoms or the medical problems that we treat, which are esophagitis or gastritis.”
For those five to ten percent of babies who have more severe problems, Dr. Newton says, “the medicines that we have at our disposal often work well enough that many infants never need to be referred to a GI specialist.” What makes the difference between the kind of baby referred to as a “happy spitter” and one whose parents seek medical attention? “What we look for is a baby who seems more irritable, often the grandparents might say the baby has colic. Sometimes they spit up even hours after they’re feeding. They seem hungry but when they start feeding they seem uncomfortable, so they take a break because it hurts to swallow.”
The problem, she says, is anatomical: “What we know about most babies is that the muscle which is called the esophageal sphincter between the esophagus and the stomach is kind of loose, and so in many babies there seems to be a little bit of regurgitation. In babies with reflux it’s more pronounced and they get burning and erosion of the mucous membranes of the esophagus and the stomach.”
The prescription, for most babies, is some kind of medication — among the most common are Zantac and Prevacid. And for many parents, a mad dash to the stores, both online and in town, that sell an array of pillows, wedges and other positioners intended to keep babies more or less upright after a feed, and more or less elevated during sleep. The holy grail, for parents whose babies are not happy spitters but irritable criers, is a day or night without inconsolable wailing.
Although reflux is itself a relatively new concern for parents, the crying that may associate with it is not. As Dr. Newton points out, many grandparents will diagnose a hollering, miserable baby with another, older malady: colic. Defined as crying that lasts three hours a day, three days a week, for three weeks, colic is among the oldest medical problems ever described, and one of the most significant stressors a new family can face.
The relationship between reflux and colic is a fairly controversial topic among doctors, it turns out. “Many people do feel, if they have colicky babies, that it’s something related to the baby’s digestive system,” says Dr. Newton. “It’s so simple to treat reflux generally, and it saves the parents, you know, three months of a very difficult time with their infant.”
On the other hand, if you ask Dr. Colin Rudolph, pediatric gastroenteroloigst, author of Rudolph’s Pediatrics and a professor of pediatrics at the Medical College of Wisconsin, he’ll present a different point of view. “There’s no relationship between colic and reflux,” he tells me, adding that recent data “demonstrates that infant irritability does not generally get better by treatment of reflux, even though it’s a common indication for reflux treatment. If you read most of its what’s out there, that’s a radical concept.”
Spitting up is a normal infant behavior, he stresses. “All babies have a degree of GER,” he said. “Most of them will regurgitate at times; about fifty percent will do it at least four times a day. That’s considered normal physiologic GER. And in most children that resolves – actually, it will increase in frequency up until sometime between four and six months, and then decrease until about a year. For most kids by eighteen months it is totally resolved. That’s a normal process.”
If there’s blood in the vomit, or if a baby is having a hard time gaining weight, then a visit to a specialist is warranted, Rudolph says. But the kids most at risk for serious GER problems are those who already have serious health problems, especially neurological conditions. For most babies, though, “Reflux has been overmedicated. Infant reflux has been overmedicated and it has been blamed for too many problems. It’s not as prevalent as it’s been generally believed to be in the pediatric community.”
So why the increasing numbers of babies diagnosed with GER? Rudolph says it comes down to money and marketing. “My perspective is that much of this reflects the pharmaceutical industry’s advertising campaigns and an increased awareness of reflux, because they are making it more of a ‘disease of the day’ in the adult community – where they’re making a ton of money – and so they brought it down to the infant world, where they’re also making a lot of money on these drugs.” It’s important, he feels, for parents to be cautious about using medication to treat what is essentially a normal stage of infant development. “Everything in medicine comes in trends,” he adds. “If a new therapy comes out it becomes popularized, and over time the truth comes out about where the treatment fits in the world of medical therapies.”
Foul-smelling laundry aside, the crying that characterizes that long first three months of a baby’s life presents its own risks. For the typical spitty baby, both doctors agree, some changes in positioning can be helpful: babies can be held in positions that keep them upright for several minutes after feeding, or held in ways that put gentle pressure on their tummies. Breastfed babies can show symptoms that are diagnosed as GER when they actually are reacting to milk oversupply or a very quick letdown. And elevating the head of the crib can be useful as well, though Dr. Rudolph points out that most products designed for this effect end up with babies just rolling down to the end of the bed. Still, it doesn’t hurt to try.
As my friend Jane found out, time is typically the best healer. And Rudolph offers the following additional prescription. “Get a really good washing machine,” he says. This echoes how Karen, a Boston-area mother of two sons, characterizes her boys’ tendency toward constant spitting up: “a laundry problem.”
Still, foul-smelling laundry aside, the crying that characterizes that long first three months of a baby’s life – whether it’s colic or not, whether it’s related to reflux or not – presents its own risks.
“Crying can aggravate or even provoke postpartum depression, spark arguments between parents about what to do, cause the extended family to get involved and criticize how the parents are handling the baby – it leads to a lot of misery,” says Dr. Newton. And, she adds, it’s considered a contributing factor in most cases of shaken baby syndrome.
Even babies with no problems at all cry a lot. “Normal babies around six weeks of age have about two hours a day of what we call inconsolable crying – that’s considered normal,” Newton says. “Babies don’t cry because they’re mad at their parents or they’re bad babies; it’s just part of their development.” Perhaps it doesn’t matter all that much why babies cry inconsolably, so long as they outgrow it with no ill effects. Except that, for parents in the wail-filled trenches, it can take a terrible toll.
“This is what your pediatrician is for,” Dr. Newton says. “If you feel like you’re not getting a good answer, go back to your pediatrician. We don’t know how difficult things are at home unless you tell us.”
Most importantly, she adds, is not to spend so much energy worrying about the baby that you lose track of your own health. “Parents,” she stresses, “should take care of themselves.”