Reflux explained

The full name for this condition is gastro-oesophageal reflux, or GOR, and the more serious condition is gastro-oesophageal reflux disease, or GORD (these are known as GER and GERD, respectively, in the USA, where they spell oesophagus without the ‘o’). The term ‘reflux’, which means ‘backward flow’, is a shorter way of referring to GOR and literally refers to the backward flow of stomach contents up into the oesophagus. It is a physiological process that occasionally occurs in everyone, young and old alike, although not everyone is aware of it happening to them.

The oesophagus is basically a long tube that transports food and liquid from the mouth down into the stomach, where at the lower end it connects to the stomach via a valve called the lower oesophageal sphincter, or LOS. This sphincter opens when you swallow to let the foods and liquids pass through and should then close to keep the stomach contents inside. When the LOS doesn’t function properly – and in babies this is often simply because of a developmental immaturity – it allows the stomach contents to flow back into the oesophagus to varying degrees. The reflux material may just flow into the lower end of the oesophagus (the distal), move further up towards the throat and sometimes enter the mouth and be ejected as vomit. Most babies do spit up or vomit a little at times, but this rarely causes a problem and will not usually require any medical intervention.

GORD is a more serious complication of the same reflux issue and is often referred to as acid reflux, which is the cause of heartburn. This is when the reflux material not only consists of the stomach contents but also has a high level of hydrochloric acid. This acid is naturally produced in the stomach to aid the digestion of food, but whereas the stomach has a protective lining that acts as a barrier to the acid, the oesophagus, throat, nasal passages, lungs and teeth do not and, over time, repeated exposure to the acid can cause severe pain, increasing damage and some more serious complications.

The majority of babies are born with some degree of reflux simply from the immaturity of the LOS. Although many of them will not experience any pain or heartburn and will outgrow it within a year without the need for medical intervention, many others do suffer with severe symptoms, experience discomfort and pain and will need a definite diagnosis, an ongoing management plan of the condition and appropriate medical treatment.

There are many signs of reflux and every baby will display slightly different symptoms according to his condition and its severity. In addition, the behaviour he displays in response to his reflux can be governed by his temperament and individual personality. For instance, some babies cry, some don’t; some babies eat well, some don’t; some babies sleep well, some don’t; some babies still smile, some don’t, etc.

The following is a list of the most common symptoms and their usual cause:

• Bouts of inconsolable crying: usually due to the baby being in pain from acid burning, but often exacerbated by being unable to sleep, resulting in extreme over-tiredness.
• Appearing to be in pain and distress with little that will comfort him: usually due to the heartburn caused by the reflux of stomach acid.
• Moans and complains most of the time and is rarely happy: often due to feeling wretched because of his constant discomfort.
• Irritable, agitated, rarely relaxed and appears ‘wired’ a lot of the time: due to the release of extra adrenaline which the body produces to try to deal with the continual pain.
• Body temperature may be slightly higher than normal and the baby may often appear quite hot and clammy: due to the increased adrenaline produced by the body in response to pain.
• Frequent hiccups which sometimes appear to be painful: caused by the spasm of the diaphragm in reaction to the reflux of stomach acid. The baby may also have had frequent and violent hiccups while in the womb, which can be a very early indication that he will suffer from acid reflux.
• Very hard to wind and does not easily burp: because the baby learns very quickly that anything that comes up hurts. He therefore becomes ‘retentive’ with his wind and rarely burps.
• Continual wet burps or constant spitting up even an hour or so after a feed: due to the slow digestion of the stomach contents and the poor function of the immature LOS.
• Arching the back and neck as if trying to pull away from his chest: due to pain caused by the heartburn.
• Body goes rigid and stiff, it always seems as though the baby is trying to stand up on you, and he becomes muscularly quite strong at a very young age: due to constantly tensing and flexing his muscles through suffering continual pain and discomfort.
• Displaying stress-related behaviour as a reaction to pain or discomfort, such as head-thrashing (as if saying ‘No!’); violently rubbing together heels and/or feet, often making the ankles and surrounding skin extremely red and sore; clawing at his head, ears and face, often leaving nasty scratch marks; tugging at his hair and even pulling it out; violently thrashing his legs up and down or flailing his arms around.
• Small amounts of vomit produced all the time: caused as the stomach contracts to digest the feed and small amounts are pushed back up into the oesophagus and mouth as the weak LOS fails to remain closed and contain the stomach contents.
• Projectile vomiting at least once a day: again due to a very weak and immature LOS.
• Is never sick but displays other symptoms which can indicate ‘silent reflux’: see pages 214–17.
• Agitated and fussy over feeds and never seems to relax when feeding: may be due to having a sore oesophagus and/or throat caused by the excess acid.
• Continually pulling off the breast or bottle: although the baby wants to feed, he quickly associates feeding with discomfort.
• Head bobbing, like a woodpecker, when put to the breast: again possibly due to the baby already associating pain with feeding.
• Voraciously suckles for a short while, appearing to be almost ‘greedy’; may also be really noisy while feeding, appearing to gulp and guzzle the milk rather than drinking in a calm, relaxed manner: could be due to the baby desperately wanting to suck and swallow to try to relieve the acid heartburn.
• Will take only small feeds: the baby very quickly learns that the more feed he takes in one go, the more pressure is put on the LOS and he starts to reflux.
• Complete refusal of feeds: often due to the rapid association a baby makes between feeding and experiencing discomfort and pain.
• Infrequent bowel movements, or showing great distress when straining to pass a stool: due to the internal pressure causing the stomach contents to reflux when passing a bowel motion. In fact, many babies will often poo only while feeding, as swallowing helps to wash down the acid that refluxes into the oesophagus as they strain to pass a motion.
• Constipation or very hard, ‘solid’ stools: often associated with a cow’s-milk protein intolerance.
• Explosive, very loose, watery, mucous and often green stools: can be associated with a lactose intolerance.
• Orange, orange-tinged, glossy, shiny stools: often indicate a degree OF microbiome (gut flora) imbalance and possible intolerances or allergies. Can often be a result of the baby having been exposed at some point to antibiotics.
• No interest in feeds, doesn’t naturally ‘root’ and look for feeds, fails to wake for feeds and refuses to latch on properly to the breast or gags if given a bottle within the first few days after birth: can be a very early indication that the baby is already suffering some degree of discomfort from acid reflux.
• Bouts of gagging and choking: due to vomit, along with some acid, refluxing up the oesophagus and hitting the back of the throat.
• Excessive dribbling: caused by the body producing extra saliva, which is a natural antacid and helps to combat the overproduction of the stomach acid.
• Appears to fall asleep after a few minutes’ feeding and is impossible to wake to continue with the feed: I call this ‘shut-down’ and believe it to be a baby’s self-defence mechanism kicking in when he does not want to take any more feed because he knows it is going to cause him pain.
• Cries when laid horizontal: when a baby is put on his back the LOS is somewhat stretched and opens more easily, therefore allowing the acid to reflux into the oesophagus and so causing severe heartburn. This is the same reason that, when laid on his back to sleep, a baby may cry with pain from the heartburn and be unable to sleep.
• Does not sleep well: due to general discomfort from the reflux. When he stirs throughout his sleep cycles he is often too uncomfortable to settle himself back to sleep.
• Very noisy, grunting and groaning, and will often even cry out when asleep: due to the pain of reflux and heartburn.
• Poor weight gain or failure to thrive: due to the development of a food aversion as he knows it causes pain.
• Normal growth and weight gain, but shows other symptoms: many babies do have an acceptable weight gain and appear to thrive, but this is often down to the instinctive perseverance and diligence of a mother to nurture and feed her baby whatever it takes.
• Excessive weight gain and wanting to feed and suckle all the time: some babies don’t make the distinction between pain and hunger and instinctively look for food as a comfort.
• Wants to be constantly held and will rarely settle if not being cuddled or carried in a baby-sling: the upright position assists natural gravity, which helps to keep the stomach contents in place.
• Will sleep only when being held in a parent’s arms: the comfort he feels can help to deal with his discomfort and pain. Also, being upright, as mentioned in the previous point, often gives some relief.
• Having excess mucus and seeming to have a continual cold: due to the sinuses producing extra mucus in response to the presence of the stomach acid in the oesophagus, throat and nasal passages.
• Constant cough or raspy breath: again due to the presence of acid in the oesophagus and throat, and to the extra mucus that is produced to try to negate this acid, which in turn causes a constant cough, often exacerbated when the baby is put on his back.
• Grimacing or often frowning: I often think that a baby can look like a worried little old man when he is dealing with the effects of acid reflux.
• Constantly clenches his fists and you may even find it difficult to prise them open – this is in reaction to his pain as he continually tries to deal with the pain from acid reflux.
• Rarely smiles, seems withdrawn and is very quiet: all the baby’s focus and concentration is on dealing with his discomfort.
• Foul-smelling breath: due to the reflux of acid and part-digested milk.
• Sore lips and mouth: caused when the acid burns not only the
• oesophagus internally but externally the lips and skin around the mouth.
•  Oesophagitis: damage caused to the oesophagus by continual contact with the refluxed acid; sometimes leads to severe burns and the development of ulcers.
• Gagging himself with fingers or fist: often due to oesophagitis caused by the acid (see previous point).

Less common symptoms and causes include:

• Tendency to bouts of infant apnoea (stops breathing) either during feeding or when asleep: this is possibly an extreme of the ‘shut-down’ scenario mentioned earlier (see page 210) due to severe pain.
• Frequent ear infections or sinus congestion often developing as the baby gets older: due to the constant overproduction of mucus and from acid damage and scar tissue forming in the Eustacian tubes that lead into the ear.
• Prone to aspirate when being sick: occurs when a baby breathes and inhales the vomit and/or milk into his lungs. Best described as a shocked, sharp and sudden intake of breath caused as the acid and vomit travel up an already sore and ulcerated oesophagus.
• Respiratory problems, recurrent pneumonias, bronchitis, wheezing and asthma: due to continual aspiration and acid damage.

Many babies with GORD will struggle to sleep comfortably and are often disturbed throughout their sleep by acid heartburn. It is almost impossible to expect a baby who is suffering from any degree of reflux to be able to sleep soundly for any length of time, let alone through the night, until his symptoms have been treated and brought under control. Once a diagnosis has been given and the baby is responding to his path of treatment it will be easier to get a routine in place and start to establish associations to sleep. Sleep often doesn’t come easily to these babies and in my experience sleep position can make a huge difference to the quality of a baby’s sleep, especially if he has reflux. I have found very few reflux babies who are able to sleep comfortably, if at all, on their backs, whereas they greatly benefit from sleeping on their sides or even their fronts. When a baby lies on his back the lower oesophageal sphincter is more likely to relax and allow the valve it surrounds to flop open, thus allowing the stomach contents to reflux into the oesophagus. If the baby is on his side, then this is less likely to happen as the valve is kept partially closed; and if a baby is on his tummy, the pressure from lying on his front keeps the valve almost completely closed, preventing any reflux episodes. I appreciate that this is contrary to current sleeping- position guidelines, but in my view any baby with suspected or diagnosed reflux should have either a portable breathing and movement monitor fitted to his nappy 24/7 and/or an under-mattress breathing monitor in his cot, both of which will sound if the baby stops breathing no matter what his sleep position. Sadly, I know of too many reflux babies who have had severe apnoea attacks or have aspirated on their own vomit, and some who have actually died as a result. As babies with reflux are at greater risk of this happening, and therefore at greater risk of cot death, my advice is to use one of these monitors as soon as reflux is suspected or diagnosed and this will mean your baby is monitored all the time whilst sleeping and therefore at much reduced risk.

Whether a baby is vomiting with his reflux or not, feeding often becomes a very stressful and time-consuming focus of the day for many parents. It never ceases to amaze me how individual reflux babies can react so differently towards their feeds. Some babies struggle to differentiate between pain in the oesophagus and hunger pangs in the stomach, so they instinctively look for food all the time. Others quickly learn that sucking and swallowing will bring some temporary relief from the burning pain of having acid reflux and therefore try to eat as much as possible. For some, the comfort they get from following their natural, inborn instinct to suckle will override the physical feeling of pain they get from reflux as they eat, and therefore they will continually search for more and more food.

On the other hand, many babies will quickly make the association between taking a feed and then experiencing the discomfort of reflux and this causes them to build up an aversion to eating. Their natural instinct to ‘root’ for food and to feed at regular intervals can often be suppressed, causing them to refuse feeds completely or more commonly to take what seems like hours over each feed. For parents this can be a complete nightmare. A mother has a natural instinct to feed and nurture her baby, so it can be extremely frustrating and upsetting when a baby doesn’t want to feed and fights against it all the way. Many of these babies have a very poor weight gain, which understandably fuels their parents’ anxiety and worry. Sadly, I have seen too many cases where a baby will eventually refuse all feeds completely. It is vitally important that a baby never feels ‘forced’ into taking feeds, as this will only deepen his aversion, but that an early diagnosis is gained and the appropriate course of medication, milk, feed-management and routine is found and put in place.

Having researched and read all the information about reflux and dietary related problems that I give in both my books, through the podcasts I’ve recorded and scrolling though my Instagram , I would hope you now might have a clearer understanding of the condition ‘reflux’ and what could be exacerbating your little one’s issues it.

Often, all that is needed is to work out what is fuelling the reflux, which then makes it easier to address the underlying problem and bring resolution to the condition.

It might be that you need use a feed thickener, a different bottle, feed in a set schedule instead of on demand or implement a sleep routine.

It could be you need use nipple shields to help regulate the flow of your breast milk or express some milk, add a thickener and feed from a bottle.

You may well need some expert medical intervention to get a proper diagnosis and it would be useful to see a Pediatric gastroenterologist.

Whatever the problem, it can be changed, fixed, rectified and your baby will be able to feed comfortably and sleep more easily once all the symptoms are fully managed.

• You can read both my books.
• You can listen to the podcasts I have recorded on sleep and reflux.
• You can scrutinise my Instagram page and replay many of my ‘live’ posts and Q and A sessions.
• You can seek direct help from me through an online consultation.

There is definitely a light at the end of the tunnel and you, like thousands of parents before you, can and will learn how to manage your baby’s digestive issues and promote and establish positive feeding and sleeping habits for your baby, toddler or child. Good Luck!