Info about GER/GERD from the 2010 edition of Breastfeeding Answers Made Simple:
• There is no evidence to support the strategy of adding cereal or starch to baby’s diet to ‘thicken feeds’, and this approach is not without risks to other aspects of the baby’s health
• Use of substitutes for human milk can contribute to GERD – babies given formula have more reflux episodes each day and continue to reflux longer
“Colic is defined as crying at least 3 hours per day at least 3 days a week for at least 3 weeks [note that it’s crying that defines colic; there’s no explanation for the crying itself]. It often starts when a baby is about 2 to 3 weeks old and is estimated to affect between 8% to 40% of babies. Sometimes called ‘high need’, colicky babies may spend much of their first 3 months crying both on and off the breast.”
“A baby with reflux may breastfeed well for a few minutes and become more agitated as he continues to feed.”
Because many babies with gastroesophageal reflux disease cry for long periods, GER can be mislabelled as ‘colic’ (and therefore go untreated).
“During the first four months of life, the sphincter between a baby’s esophagus and stomach has low muscle tone and relaxes often. In an average baby, several times each day his stomach contents wash back into his esophagus, also known as GER. Spitting up occurs when the stomach contents make it all the way up the esophagus and out the mouth. Spitting up occurs in up to 70% of babies and peaks around 4 to 5 months of age, occurring less and less often as the digestive system matures. By 12 months, only about 4% of babies still spit up.
“When a baby is growing and thriving, and feeding normally, spitting up is a temporary inconvenience. But when GER causes damage to the lining of the esophagus, normal GER becomes gastroesophageal reflux disease (GERD). A baby with GERD may spit up or he may not, because damage to the esophagus can occur even if the stomach contents don’t make it all the way to the mouth. GERD can cause health issues such as respiratory problems, (congestion, coughing, wheezing, bronchitis, pneumonia), apnea, esophageal narrowing or stricture, anemia, failure to thrive, and esophagitis, or inflammation of the esophagus, which can cause pain during and after feedings.
“GERD has proven to be the cause of many puzzling feeding problems and behaviours that are sometimes given the all-purpose label ‘colic’. Allergy to cow’s milk protein may also play a role in the development of GERD in some babies, as can tissue irritation along the gastrointestinal tract. Early exposure to formula (sometimes without the parents’ knowledge) can sensitize a baby to cow’s milk protein, which can cause a reaction later to either formula or dairy in the mother’s diet.”
“Unfortunately, many mothers do not discover until their baby is already weaned from the breast that giving formula can actually make his discomfort worse. Episodes of reflux are shorter among breastfed babies, and breastfed babies spit up less and stop spitting up earlier than babies fed formula.”
Things that can contribute to GERD include:
• An empty stomach between feedings – frequent nursing prevents stomach contents from becoming acidic, as happens when the stomach is empty. Acidic stomach contents are more likely to cause damage if they wash back into the esophagus
• Carrying babies in infant seats puts their torso and legs at a 60 degree angle, increasing episodes of reflux
• Use of substitutes for human milk – babies given formula have more reflux episodes each day and continue to reflux longer
• Encouraging babies to sleep for long stretches at night means longer periods of empty stomachs with high acid contents
“Spitting up is outgrown as the sphincter between stomach and esophagus lengthens with age and increases in muscle tone. But when normal reflux becomes reflux disease, weight gain and growth can slow, pain can lead to feeding aversion and damage to the esophagus may put babies at risk later in life. One U.S. study followed 100 babies diagnosed with GERD that led to esophageal damage, or esophagitis. These babies were divided into four treatment groups (19 received a placebo) and followed until 12 months of age. The symptoms of the babies in the placebo group eventually resolved, but at 12 months their esophagus still had abnormalities, which the researchers concluded increased these babies’ risk later in life for GERD and even more potentially serious health problems, such as esophageal stricture, precancerous conditions and in rare cases, esophageal cancer.”
“The most common GERD treatment for babies is prescription medication. If a baby receives medication, the drug or combination of drugs will probably need to be adjusted as baby grows, because it is determined by the baby’s weight, which changes quickly. If a drug treatment worked well for a while and the baby’s symptoms return, talk to the baby’s doctor about the possibility of adjusting the dose. The sooner GERD is diagnosed and treated, the less likely it will become severe. In severe cases, if a baby continues to lose weight, surgery may be recommended.”
Strategies that can help:
• Before breastfeeding, help baby achieve a ‘goldilocks state’ – not too hot, not too cold, and nice and comfy (without any restrictive clothing) – as I mentioned, nursing in the tub can work very well
• Offer a clean, trimmed finger to suck (perhaps a good time for Pushing the Tongue Down and Out that I sent earlier) until the baby settles down
• Keep sound and lights low
• Begin breastfeeding when baby is in a light sleep and not yet fully awake – if you let him sleep on your bare chest and move towards the breast on his own as he wakes up, he may surprise you with an awesome latch
• Use a semi-reclining position with baby tummy down on your body; breastfeed with baby’s head higher than bottom at about a 45 degree angle
• Let the baby finish the first breast first before offering the other one – and you can certainly offer the same breast 2 or more times in a row if baby wants to suck but not necessarily eat
• Feed often, but not necessarily for a long time. Many mothers of babies with reflux have abundant milk supplies and fast flow rates, and as a result their babies may need only 5-10 minutes at the breast to get a full meal. Concerned moms sometimes encourage their babies to nurse more; in adults with GERD, overly full stomachs worsen symptoms.
• Devote as much time as possible to holding baby or wearing him in a soft baby carrier or sling; after feedings, keep baby upright for 20 to 30 minutes
• At diaper changes, avoid lifting baby’s legs, instead roll him on his left side to wipe
• When baby is awake and horizontal, lay him on his left side or on his tummy. The esophagus connects to the stomach near the back, so these positions are less likely to trigger reflux
• Avoid putting baby in a car sat except when riding in the car
• Eliminate cow’s milk and dairy from your diet – it may take several weeks to notice improvements and you need to avoid milk, yogurt, ice cream, cheese, butter and all other sources of casein and whey, but you’d know for sure if allergy to cow’s milk protein is an issue
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