Hellobee

From the time the Babies Blue were born, we had major projectile spit-up issues.  Spitting up, however, is nothing unusual in the world of babies, particularly not for preemies, whose little digestive systems are often a little behind in development.  In the NICU, all the cribs were propped at an angle because so many preemies have reflux.  Little nests made of blankets kept the babies snug and prevented them from slipping down the angled mattress.

Even knowing that reflux is common in preemies, I still missed the signs that would have prevented a lot of tears from the Babies Blue and their mama.  We had many a breastfeeding struggle, but the one that pushed me over the edge and made me decide to exclusively pump was that Finn would pull off the breast and scream and scream.  I thought he was frustrated that I didn’t have enough milk, but then I would pump and still have plenty.  I decided it must be that he wasn’t an effective enough nurser to empty the breast but was still hungry and would get frustrated. When he took a bottle, he pulled away and cried at times, but it did not seem to be nearly as often. Feeling like I was torturing my child, I started pumping exclusively, which seemed to help for a week or two, but then the screaming came back.  Both boys were having problems, but Finn just seemed completely miserable. He would tighten up his body in the middle of a feeding.  His back would arch, and he would cry and cry.  Both boys still spit up often, but it had actually decreased since they were newborns, so I wasn’t on the lookout for reflux.  Somewhere around 6 weeks, I finally snapped and called our pediatrician’s nurse and left a message.  I listed the litany of symptoms:  not acting like they feel good, tightening up their legs and back during a feeding, taking a few swallows of milk–formula or breastmilk–and then screaming and screaming, lots of gas, and spitting up.  The nurse called back and said it sounded like they had reflux and that the doctor would call in a prescription of Zantac to try for both of them.

I felt so stupid for having let my babies be in pain for several weeks, but I really just thought they must be hitting that fussy newborn phase everyone talked about or that the problem was with my supply or whatever reason seemed to fit the symptom I was thinking of at the moment.  After the nurse said they had reflux, I started seeing the big picture and how all the symptoms I had been looking at individually were collectively pointing at them having an actual medical issue that needed to be addressed.

What is reflux?

Acid reflux is very common in babies.  Reflux isn’t just another term for colic, although some cases of “colic” are likely acid reflux.  Acid reflux is a specific medical condition with a known cause.  While babies generally have to grow out of it, there are both medical and non-medical interventions that can be done to reduce the symptoms and help your baby to feel better, eat better, and sleep better.  The lower esophageal sphincter (LES) acts as a one way valve that allows food into our tummies and then closes to prevent the contents of our stomach from regurgitating back up.  In babies with reflux, the LES is still immature, so it allows partially digested food and acid to come back up.  Naturally, this causes irritation and gives the baby what we think of as heartburn.  While acid reflux is generally associated with spitting up, babies with silent reflux don’t actually spit up more often than babies without acid reflux, but the contents of the stomach are still going up into the esophagus.  In our experience, you can often hear the acid coming up and going back down.

What are common symptoms?

• Frequent or recurrent vomiting
• Projectile vomiting
• Frequent or persistent cough
• Refusing to eat or difficulty eating, including choking or gagging with feedings
• Crying with feeding
• Heartburn, gas, or abdominal pain
• Spits up green or yellow fluid
• Spits up blood or a material that looks like coffee grounds
• Has difficulty breathing

Sources here.

What non-medical interventions can you try?

Often acid reflux is mild and medical intervention is not needed.  Prior to calling our doctor, I had actually implemented many of these things just to try anything to help with the spitting up and what appeared to be stomach pain.

• Feed a smaller amount in more feedings, rather than fewer, larger feedings.  The idea is if they have less in their stomach at a time it will be digested faster and leave less to be refluxed.
• Feed upright and keep the baby upright for 20-30 minutes after every feeding.  By holding them upright, gravity helps keep the contents of the stomach down and gives them time to start digesting it.  We started feeding them sitting up, instead of reclining in our arms and then made sure their head stayed higher than their stomach for a minimum of 20 minutes following a feeding.
• Burp frequently and thoroughly.  We stopped to burp after every ounce when their reflux was at its worst.
• Have baby sleep at an angle.  We used the Rock n’ Plays longer than we planned because it kept the boys at an angle all night, which helped them sleep better.  Eventually, we modified our crib situation to keep that at an angle, too.
• Breastfeed if possible.  Breast milk is faster to digest and has enzymes to help digestion.  Be aware that some babies have allergies that heighten the effects of reflux.  You may need to eliminate certain foods from your diet or try a hypoallergenic formula.  I did this one all wrong.  I really thought they were having issues because I had low supply and they were inefficient nursers, and as a result, they were getting frustrated.  In hindsight, I know now they just were hurting.  So, I erroneously started pumping exclusively because they seemed to take bottles better (probably from being more upright).  As a result of pumping exclusively, my supply dropped even further, and they had less breast milk, instead of more.
• *Maybe* add cereal to bottles.  We have never done this, and I would not recommend doing so unless your doctor specifically recommends this.  There are two schools of thought on this.  Some doctors feel that the cereal thickens the milk enough to keep it from refluxing as much.  Alternatively, others (and generally a more modern approach) believe that adding cereal to the milk (1) makes the food digest slower and therefore stay in the stomach longer providing opportunity for more reflux, (2) adds calories not from milk or formula so they are either unnecessary or may even prevent your baby from eating enough calories because it makes the baby feel full for a longer period of time, and (3) may cause choking or other feeding issues.

Common reflux medicines and how they work differently.

Unfortunately, all of the remedies we had tried weren’t helping our little guys, so when I finally called the doctor we went straight to meds.  Don’t be discouraged if the first medicine doesn’t work right away.  You are very likely to need to play with the dose or try another one before finding the right medicine for your little one.  There are two types of medicines for infant acid reflux: H2 blockers and proton pump inhibitors (PPIs).   Zantac, an H2 blocker, is a common first medicine to try. It is FDA approved for infants under a year.  A couple of downsides is that it has to be administered multiple times a day, and it’s very weight dependent so you have to always work to keep the dosage correct.  Also, it has a super strong mint taste, and babies tend to spit it out.  As I understand it, H2 blockers don’t make the episodes of reflux happen less, but they do reduce the amount of acidity in the spit-up.  If an H2 blocker doesn’t do the trick, the next step is usually to try a PPI, like Prevacid, Prilosec, or Nexium.  These only have to be given once a day generally, but they need to be taken on an empty stomach, so timing can be a little tricky.  The FDA has not approved their use in children under 1, but doctors commonly prescribe them and several studies have shown them to be safe and effective for babies.  PPIs block the production of acid and often work faster and more efficiently to make babies with more severe reflux feel much better.

Though we have had to change the dose several times, Elliot has done well on Zantac.  Poor Finn, however, had a little harder road.  The Zantac worked somewhat to improve his symptoms, but in the end it just wasn’t controlling the reflux enough, and our pediatrician prescribed Prevacid.  In all candidness, the first 10 days on Prevacid were far, far, far worse than we had ever had.  Finn cried all day long.  He would try to eat, and after an ounce he would cry for up to two hours.  It was heartbreaking, and he and I cried together many a day while I held him and tried to use all my mama power to soothe him.  After conducting a lot of internet research, I learned that often doctors advise you to continue using the Zantac for the first two weeks after switching to a PPI because it can take up to two weeks for the PPI to be effective.  Apparently, when the PPI starts working to shut off the acid production the body fights back and it can cause an “acid battle,” which I believe is what made Finn feel worse than ever.  It was on Day 10 of Prevacid and that we finally begin to see improvement and I thought maybe we might all survive.  By Day 14, my sweet baby was a whole new little boy.  While he smiled some before and was what I would have called a “happy” baby, after getting the reflux under control he just blossomed.  He smiles every time he has even the slightest provocation.  He plays more.  He sleeps better.  He has absolutely thrived on the Prevacid, and I’m thankful for all the phone calls to the doctor, all the google searches, and even those 10 horrid days while we waited for the Prevacid to kick in.

I hope my own follies help some of you who may not know what’s going on with your baby, but just that they don’t seem to feel well and cry a lot.  I wish I would have talked to our doctor sooner, but in my new-mommy ignorance, I missed the forest for the trees.  If you find yourself dealing with reflux, I highly recommend checking out Reflux Rebels for a good source of general info and some quizzes to help you determine whether your baby might have reflux, a milk-soy protein intolerance (MSPI), etc. and the Surviving Reflux babycenter.com group, where there are many moms who are currently dealing with or have dealt with reflux and can answer questions and offer specific support.

Did your baby have reflux?  What worked and what didn’t?