Is baby reflux normal or not?
Why does the word reflux cause so much confusion and debate?
Is it normal is it not normal? If the ‘experts’ can’t agree on whether it’s normal or not, how is anyone supposed to understand what on earth is going on?
A lot of this confusion arises because the same word is being used to describe different things, yes it’s all reflux but with very differing severity, causes and management.
Why reflux happens
Reflux just means something going the wrong way through a value. In the case of your baby, it’s movement of the contents of their stomach into the oesophagus (food pipe). These contents may make it all the way up and out, sometimes referred to as posseting or spitting up or otherwise called regurgitation. The contents may make it only as far as the throat or mouth before being re-swallowed, this is often referred to as silent reflux.
The stomach is basically a bag that holds the milk your baby has drunk. The stomach has two valves, one at the top and one at the bottom. The value at the top of the stomach (or bottom of the oesophagus) opens or relaxes to allow milk to pass into the stomach. It then contracts to close the stomach. The milk in the stomach will then start to be digested. When the correct stage of digestion has been reached, the lower valve opens and allows the contents to pass into the intestines for the next stage of digestion.
Physiological reflux or reflux otherwise known as Gastro-oesophageal reflux (GOR/GER) just describes this process of stomach contents going the wrong way through that valve. Actually, this is a protection mechanism. The body is designed to release pressure or reduce the volume when the stomach overfills. This is to allow for regulation of milk intake, too much is in there, and some gets let out. That overfilling or stretching of the stomach triggers the valve to open and reduce that pressure.
Tone & Gravity
Now you may have heard people say that reflux happens due to the immaturity of this valve, otherwise sometimes called a sphincter. This does influence this. But all babies have an immature valve because they are babies!!! Yes as they grow and develop so does the tone in the valve and this will influence how tightly shut it is. Certain things may result in less tone to this valve. Prematurity, babies with neurodevelopmental disorders, hernias or babies suffering from hypotonia (so low tone) may be more prone to increased reflux.
Gravity has a huge role to play here too! Adults are upright more of the time, so we have gravity on our side. That helps things stay down where they are supposed to. Babies however need us to hold them upright, but they spend a lot more time than we do lying down or reclined. This means when the valve is triggered to open, stomach contents are more likely to come straight back out.
The other thing that’s worth knowing is the opening of this valve/sphincter can be triggered not just by the stomach. If your baby is crying, pulling their legs up to their tummy, coughing, or straining when trying to pass a stool, this can trigger the relaxing or opening of the valve. This can result in reflux occurring. We may think that our baby is squirming, pulling their knees up, or crying in response to the reflux, they may be, but in some cases, it’s this behaviour that has caused the reflux to happen.
Now the key thing here with this type of reflux is that it isn’t happening frequently, just every now and then. That it’s not causing your baby to be distressed. Yes, it may upset them as it happens, none of us particularly like that feeling of bubbles coming out of our nose, but they settle quickly afterwards with a cuddle or a little feed. They are not in ongoing discomfort or distress. This isn’t causing them issues with their growth, their feeding or how content or happy they are the rest of the time. So, this reflux is physiological reflux, and this is why it’s described as normal.
When reflux isn't normal
When your baby is crying for long periods of time, has large amounts of reflux, is faltering in their growth or is in pain then this isn’t normal and could be a result of:
1. It could be your baby has Gastro-oesophageal reflux disease (GORD/GERD). This is thought to be related to excess acid causing pain when your baby refluxes.
2. Something else is causing the reflux to be more frequent, excessive or causing your baby to be in pain when the reflux occurs! There is a root cause of this reflux.
Gastro-oesophageal reflux disease (GORD/GERD) is where symptoms of physiological reflux (GOR) are also associated with symptoms of respiratory disorders or suspected inflammation of the food pipe. Diagnosis is made on clinical symptoms, rather than a specific diagnostic test, therefore there is an element of interpretation of these clinical symptoms. This is where some confusion unfortunately arises. Thinking that reflux is normal (as in GOR or physiological reflux) but this is not the same sort of reflux! Babies that have GORD/GERD are very unsettled and unhappy, most of the time! They are often (although not always) not thriving or growing well, cannot be laid flat at all and don’t sleep for any stretch of time. The acid could be damaging their oesophagus. Your baby is in significant pain and distress, and this is not normal! These babies certainly should not be dismissed as ‘normal’ and parents told or left thinking ‘it will pass and they will just grow out of it’. GORD/GERD is very distressing, for your baby and for you as parents!!
GORD/GERD only affects a small number of babies, but unfortunately, many babies are treated as if they have GORD/GERD due to challenges in diagnosis. Symptoms are very open to interpretation by the practitioner but also symptoms are very broad, meaning many of the symptoms could be a result of other issues, and not being caused by pain due to acid. For example, you may describe that your baby is crying for long periods of time, arching their back when put to the breast. This could be due to pain from reflux, but it could also be due to hunger, slow milk flow, difficulty feeding, or pain in their body when being held in a certain position. So correctly identifying what is GORD/GERD is not always simple or straightforward.
The key to helping families is...
- Determine what is normal physiological reflux. In this situation supporting parents to responsively feed their baby. Help them understand that babies need carrying A LOT. Support to cope with crying and how to help reduce this, settle their baby and help reduce the incidence of physiological reflux.
- Identify correctly when reflux has a root cause, which it will in most cases. Skilled infant feeding support to optimise attachment and positioning, reduce excess air intake, educate parents on how to pace a feed, read their baby’s cues and reduce overfeeding.
- Identify where tension or tongue-tie/restriction are impacting feeding and support families to have the correct treatment or therapy to help.
- Identify where allergies are the root cause and support families with the process of elimination, correct identification of allergens and give families the evidence-based information they need to inform their choices.
- Correctly determine in which babies it is truly medical GORD/GERD (or other medical causes)
So yes reflux is sort of normal, in that the word reflux just means something going the wrong way through a valve. But what isn’t normal is that in most cases reflux is occurring due to a root cause, that with the right support we can improve or even eliminate this and therefore improve the reflux and how happy, settled and content your baby is!
There are many different ‘root’ causes behind reflux. Trying to find out what may be the cause for your baby can be complex and extremely bewildering.
Support to identify but also to empower!
Parents need the right support to help discover what the root cause of their baby’s reflux may be. This cannot be achieved in a one-off quick appointment or by guessing, ‘try this’ or ‘stop eating that’. It may work for some if you guess right the first time, but for many, this leads you down a road of not knowing what has worked or more importantly why it hasn’t. Identifying the root cause or causes takes time and requires a holistic approach to consider all the elements that could be contributing to or affecting this. It’s also not just about identifying the root cause. It’s about empowering you as parents. Helping you to understand your baby better. Learning about what is ‘normal’ baby behaviour, understanding their cues and how to respond, and how to settle and calm your baby.
You can book a 15 m free call with me via my website if you want to know more about how I support families with unsettled babies. Supporting you to identify the root causes of your baby’s discomfort, but also empowering you to parent your unsettled baby with confidence. Helping your baby to be more settled and for you to find some enjoyment in the journey of parenthood.