‘What is reflux?
I want to just say before we take a little look at reflux medications that one of the pillars of my business is the importance of evidence-based information and informed choice! As parents you need all the information, starting with what the evidence says, to help inform the decisions you make about what’s best for your baby. Babies are all different, we all parent differently. This isn’t about right or wrong choices when it comes to your baby, this is about how important it is to have ALL the information so you can decide!
Firstly, to be able to understand why reflux medication is being suggested or prescribed for your baby we need to know a little more about what reflux is.
GOR and GORD (what's the difference?)
Reflux means something going through a valve the wrong way. In terms of your baby vomiting, it refers to stomach contents going the wrong way, so back up, through the valve at the top of the stomach. This is a normal physiological process. Our bodies are biologically designed this way! If your baby’s tummy was to become too full, the valve opens to let some of the pressure out of the stomach (see my previous blog, why reflux is normal).
This normal physiological reflux is also known as Gastro-oesophageal reflux or GOR (GER in the USA)
Gastro-oesophageal reflux disease (GORD OR GERD) is also, ‘reflux’ but this reflux is also accompanied by troublesome symptoms. These may include hoarseness or cough, marked distress of the baby, and faltering growth, amongst other symptoms. The issue here is a diagnosis of GORD is based on these symptoms, but many of these symptoms can also be associated with other conditions.
As many as 1 in 20 babies may be on medication for reflux, and studies have shown there has been a dramatic increase in the number of prescriptions for acid-suppressing medication in babies. Is this because more babies have GORD, or more babies are being prescribed medications for GORD?
Could it be that actually, these symptoms are not GORD?
Unfortunately, this diagnosis and the prescription for reflux medications, are often made without parents having all the information about the medication, the risks and possible side effects.
Treatments for reflux
So GOR and GORD are not the same, and there are definite limitations and issues related to how a diagnosis is made based on the symptoms that accompany reflux. There is increasing evidence that many of the symptoms of reflux may not actually be related to acid (Safe et al 2016). However, GORD is associated with possible complications such as respiratory disorders or oesophagitis so the doctor making the diagnosis needs to weigh up this risk when deciding whether to prescribe reflux medication to your baby.
Different countries will treat reflux with different medications/protocols. I am based in the UK so this is an overview of the guidance here in the UK.
The NICE Guidance is the regulating guidance for health professionals in the UK and this information comes from the protocol for treating babies with reflux (NICE 2015)
In breastfed babies who are regurgitating frequently and distressed or in pain, a breastfeeding assessment should be offered.
The NICE Guidance does state this should be done by a trained person but doesn’t state what level/experience that is. Here in the UK, the level of training and experience can vary hugely! How many of you have been told the latch looked fine but you were curling your toes in agony?
There is no discussion within this guidance of a feeding assessment by a trained professional for bottle-fed babies! Bottle-fed babies can have infant feeding issues too and infant feeding issues are very often a root cause of reflux! It does say a healthcare professional should ask about feeding, but this could be any healthcare professional, what is their training and experience in infant feeding?
The guidance then lays out three approaches to ‘treating’ reflux in babies. I’m going to have a look at each of these, how they are designed to help your baby but also what the risks and side effects of these treatments could be.
Thickening feeds- This involves adding a thickening agent to the milk. The idea is the thicker/heavier milk remains in the stomach, and is less likely to be regurgitated. Agents to thicken the milk are commonly made from carob bean or rice cereal amongst other thickening agents. These are often in a powder form that is added to the milk, but you can also get formula milk that already has thickener in it, often known as anti-reflux milk. Carobel is a well-known brand of thickener, but there are others, and these will vary depending on where you are in the world.
Thickening feeds may help reduce vomiting and may be of benefit to babies with GORD that have marked distress when regurgitating. However, it isn’t available to babies being breastfed, without it interrupting your breastfeeding journey, as it needs to be added to the milk. Some parents may feel they need to stop breastfeeding in order to treat the reflux with thickeners.
Other things to consider……..
- Some studies have shown adding fibre (so carob bean gum) to milk may lower the available calcium, iron and zinc available during digestion (Bosscher et al 2001)
- It could cause constipation- many parents report this as a side effect.
- They are not made up in line with current guidance around safe preparation of formula- guidelines for thickener suggest using cooler water, so not at 70c (as recommended) due to how this causes the thickener to become lumpy. This could increase the risk of a bacterial infection or contamination, putting your baby at increased risk of illness.
- It is also adding another foodstuff to your baby’s diet prior to the recommended age of introducing complementary foods which is around the age of 6 months.
- A Cochrane review (this is a process that looks at all the evidence/available studies and research) concluded that there is ‘no evidence that demonstrates the effectiveness of thickeners in infants with GOR and it shouldn’t be recommended for management of GOR’.
(Remember GOR and GORD are different! Determining the correct diagnosis for your baby is so important!)
Alginates- So this medication, one of the most commonly known being Gaviscon, is given by being mixed with a little milk and given to your baby or added to a bottle. It’s designed to form a thick substance when it comes into contact with the stomach contents. It acts a little like a raft that floats on top of the stomach contents, in theory keeping them down or stopping the stomach contents from coming back up the oesophagus.
Things to consider….
- Alginate therapy is not recommended as a treatment option in the guidelines of European and North American societies for paediatric Gastroenterology, Hepatology and Nutrition ( Salvatore et al 2018)
- Some studies have shown a reduction in reflux when alginate therapy is used, but these studies have not been assessed as being of high quality.
- Research suggests alginates may impact the digestion of fats in the milk and also possibly reduce appetite (not something that is ideal in infants). Many families report issues with constipation in babies prescribed alginates.
- It is a faff to give when you are breastfeeding, so again can interrupt breastfeeding.
Alginates should not be used in conjunction with thickened feeds, it can cause your baby a lot of abdominal discomfort but also could increase the risk of bowel obstruction.
Acid suppression medications- these are designed to reduce the amount of acid in the stomach. Different medications work in slightly different ways to reduce the secretion of acid. The two most common types of medication are proton pump inhibitors (PPI’s), examples of these are omeprazole and lansoprazole or Histamine 2 antagonists (H2 antagonists), such as Ranitidine (no longer recommended in the UK) or famotidine. The H2 blockers are not so commonly used in the UK anymore.
Both methods have been shown to reduce the creation of acid in the stomach and increase the pH of the stomach contents (the higher the PH the less acidic it is).
However, many studies have failed to show their effectiveness in reducing symptoms in infants with GORD in comparison with a placebo.
Side effects include,
- bloating, gas/wind,
I am always stunned by this list of possible side effects and that a drug given to babies to reduce many of these symptoms can actually cause those symptoms! These drugs are designed to reduce the acid, not the vomiting. Many parents aren’t told this and therefore can feel very confused that the reflux/vomiting continues. Many (not all) of these medications are also not actually licenced for use in infants according to the manufacturers. It is also recommended that these medications (and the ones mentioned above) are only used for short periods of time and that a baby should be regularly assessed to see if they are still required.
Studies have also addressed the concerns that they may reduce the levels of vitamins available to the baby, reduce the absorption of B12 and could increase the risk of respiratory and gastrointestinal infections.
There is also some emerging evidence that they could be linked to an increased risk of developing a food allergy and risk of adverse bone health (Safe et al 2016). These are some BIG things to have to consider as a parent. So much of this comes down to does your baby have GORD or is it actually GOR
Most parents are not informed of the risks of these medications prior to their baby being prescribed them, or even offered a discussion with the practitioner about weighing up the risks and benefits for their child.
So aside from one of the limitations of these medications being a correct diagnosis of GORD rather than GOR, the symptoms of these being broad and quite possibly related to other conditions, there are many studies that have demonstrated that medications for treating reflux are ineffective. These medications are presumed to be safe but they do actually come with a range of side effects, short and long-term that parents should be informed of prior to their prescription so they can make an informed choice.
One of the key things here is the correct diagnosis of reflux as GORD and the right support to help parents manage symptoms effectively. In many cases, there can be a root cause that is behind the reflux. Taking a holistic approach to identifying the root cause of your baby’s symptoms can help avoid the use of medications in some circumstances.
Babies that have GORD may absolutely need treatment as the risks of GORD have to be measured against the risks/benefits of treatment, but as research is showing, so many babies are being prescribed medication, without a thorough investigation into the symptoms. This is a huge issue!
Treating the symptom ‘reflux’ has become more commonplace, rather than identifying the fact that reflux itself can be a symptom of something i.e there is a root cause to the reflux. We can identify and address this, rather than just treat the symptom.
There is another way!!!
A holistic approach looks at all aspects that can be affecting the baby, and the family. Many of these symptoms can be eased by optimising infant feeding, supporting families to understand their baby’s communication and empowering and equipping families with strategies that actually help them manage the symptoms and understand what’s going on.
There is another way that can help you to make informed decisions and identify the root cause of your baby’s discomfort.
If you want to know more about my Root to Calm programme, a holistic approach to supporting babies and parents that identifies root causes and brings you evidence-based information to inform your decisions, then you can book a FREE call with me using this link.
It’s an invite-only programme, one of a kind, to bring families all of the support they require when they have an unsettled baby. We can see if my approach to supporting you to discover the root causes and understand your baby better is the answer you’ve been searching for.
Looking forward to speaking to you!
Bosscher et al (2001) ‘Effect of thickening agents, based on soluble dietary fiber, on the availably of calcium, iron and zinc in infant formulas’ Nutrition 17 (7-8):614-8.
NICE (2015)’ Gastro oesophageal reflux disease in children’
Safe et al (2016) ‘Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe?’ World journal of Gastrointestinal Pharmacology and therapeutics. Nov 6, 7 (4) 531-539
Tighe et al (2014) ‘Pharmacological treatment of children with gastro-oesophageal reflux’ Cochrane Review.