Reflux in Infants – Part 3: Conservative Care

Reflux (or Gastroesophageal Reflux Disorder / GERD) is a shockingly common diagnosis in infants.  There is a lot of controversy surrounding the diagnosis and treatment of this condition in this special population.  My task here is not to fuel that fire, tell parents what choice is best for their specific situation, or replace medical advice.  My goal is to provide a framework of understanding so that caregivers can feel confident and well-informed in their decision making process.

This is Part 3!  If you are looking for more background information on GERD, please read Part 1 first.  Then learn about the standard medical treatments in Part 2. Or you can just skip ahead and keep reading here.

Conservative Care

OK! That was enough of the scary stuff. Now how about some fun?  Well, at least this is the fun stuff for me. Helping families sort through the fascinating world of fussy babies, spit-up, and thriving infant health is kind of our jam at AltaVie.  There is a lot that you can do to safely support your little one’s best health experience (and improve your chances of getting a few more hours of sleep).

Full disclosure: I mentioned that the available research for the use of reflux medication in infants is limited. The published data on most conservative measures is pretty scarce as well.  My recommendations here are a blend of the limited available clinical research, understanding of the anatomy and physiology at play, and my own clinical experience working with infants.

There are four major facets to conservative care for infants with reflux: structural support, cleaning up the chemistry, balancing the autonomic nervous system, and lifestyle suggestions.

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 848, Public Domain, https://commons.wikimedia.org/w/index.php?curid=541708

1. Structural Support

I mentioned earlier that the diaphragm can play a roll in the tension surrounding the valve at the top of the stomach, influencing its ability to open and close appropriately.  I often find hypertonicity of the left dome of the diaphragm in infants who are prone to spitting up.  The other common structural pattern I see in infants with reflux is a restriction or malposition at the first cervical vertebra (C1).  Known as “atlas” because it caries the weight of the world (i.e. your head) on its shoulders, the “arm” of the C1 vertebra is in very close proximity to the infamous vagus nerve.  The vagus nerve is kind of a big deal. It carries parasympathetic (thrive mode) information to most of the visceral organs and impacts vital functions such as heart rate, blood pressure, and digestive secretions.  I have found, as many other chiropractors and patients will report, that improving the position and movement of C1 has a profound impact on vagal tone. This support appropriate stomach acid production (the right amount at the right time) and facilitates more “Thrive” mode activities, which we will get into in a moment.

To summarize, the primary structural patterns that should be cleared in infants with reflux are diaphragm tension and an atlas Vertebral Subluxation Complex (VSC).  Beyond that, we treat what we find based on a thorough, gentle infant exam using safe and gentle chiropractic and myofascial release techniques.

2. Clean up the Chemistry

I mentioned early that addressing food reactivities, allergies, and intolerances is now a common treatment approach for reflux in an infant in both allopathic and complimentary healthcare practices.  The most common suggestion is to remove all dairy from a breastfeeding mom’s diet or to switch baby to a hypoallergenic formula (not dairy or soy based).  Dairy is by far the most common food reactivity in infants.  A study done at Yale found roughly 40% of infants to be reactive to cow’s proteins in mother’s milk, so I like to round up and say 50% of infants will have some sensitivity to it.  A frank dairy protein allergy will usually be caught and addressed early on, but food reactivities, sensitivities, and intolerances are not always as obvious.  For most families, you need to remove dairy for at least 4 weeks to give a good trial to notice an impact.  For most of these infants, they will be able to reintroduce dairy later once their GI tract has had the opportunity to heal and mature and their immune system has settled down.  Don’t worry; I know it sounds daunting, but cutting out dairy really is not as hard a it used to be with so many alternatives readily available. Plus a happy, sleeping, eating, pooping baby is much more rewarding than a latte any day!

Dairy is not the only known culprit.  Some foods may have an immediate response, like tomatoes, spicy foods, or chocolate and you will notice right away after eating those foods if baby doesn’t like them. Others, like wheat/gluten, are often not as immediate.  I would recommend starting a food diary where you tract everything that goes in your mouth, when your baby eats, and their symptoms.  I would also strongly recommend getting some support in this area. Consult with a Registered Dietitian, Clinical Nutritionist, or Naturopathic Doctor who has experience working with infants.

Cleaning up the chemistry means removing any aggravating foods, lowering inflammation, balancing blood sugar, and allowing the gut to heal. Depending on the situation, it may also include restoring healthy bacterial diversity and replenishing nutrient stores.  Chemistry is not usually a quick fix, but it is a crucial component to your success in resolving reflux and establishing thriving long-term health.

HLB-Tx33. Balancing the Autonomic Nervous System

This is where chiropractors really shine.  As a chiropractor who works primarily with kids, I consider it my primary mandate to establish balance in the Autonomic Nervous System (ANS) in every child I work with.  I hope I can adequately convey how important this is to support thriving health, longterm vitality, and bringing out the best in your child.

The ANS is split into 2 divisions: Sympathetic and Parasympathetic. The Sympathetic Division is responsible for “Survival” mode. It’s your “Fight-or-Flight” response, that Go-Go-Go mode.  It is meant to help you survive in the short-term; get away from that bear, fight off the attacker, avoid the threat.  When it’s active, you have heightened alertness, lots of blood to your big mover muscles, you pump out stress hormones, and you mobilize the readily available sugar stores for immediate energy use.  When fleeing from a tiger, you do NOT prioritize digestion, rest and recovery, immune function, reproductive health, or critical thinking and learning.  That’s where the Parasympathetic Division comes in. Sympathetic mode is meant to be a very short response. Once the threat is over, you should settle down into “Rest & Digest” mode. Your Parasympathetic Division is responsible for all your “Thrive” mode functions, including encouraging digestive enzymes and secretions, restful deep sleep, and immune function.

I’m sure you have all met a baby is hanging out a little (or a lot) too much in Survival mode instead of Thrive mode.  We want out baby to eat, sleep, and poop and it is so hard to see when these little ones are wired and tired and not doing any of those three things very well.  The primary focus of chiropractic care in infants is to remove any roadblocks to ANS balance.  By addressing any structural or functional disruptions in the spine, we remove interference to nervous system communication, facilitating sensorimotor integration and up regulating parasympathetic function.  This is a pretty big deal when we are trying to turn one stressed out little monkey into a thriving expression of health and vitality.  That shift early in life will send ripple effects for years to come.

4. Lifestyle Suggestions

Last but certainly not least are all the little things you can tweak at home.  We often send parents home with specific exercises or activities to do based on what we find during an exam, but there are also lots of things you can try in the mean time.

  • Tilt the top of the bed up so that baby is sleeping on a slant.
  • Keep baby upright after a feed for 30 minutes.
  • Make sure you get a good burp soon after a feed. You may even need to burp halfway.
  • Drain one breast entirely before moving on.  Foremilk is higher in sugar, whereas hindmilk is higher in fat. High sugar can really bother some of the chemistry dynamics we discussed earlier.
  • Try to feed baby before they get frantic. A frantic feeder is much more likely to spit up (think Survival mode of Thrive mode!)
  • Tummy time.  Even if you aren’t comfortable lettering baby sleep on their belly, having them on their belly while away or sleeping on their belly on you is often soothing.
  • Belly massage and bicycle legs.  Get that gas moving! Sometimes gas gets stuck in the middle and needs a little help making it the whole way through. This is much easier to do preemptively on a soft stomach than it is on a hard, irritate belly.
  • See a lactation consultant.  Feeding mechanics can certainly play a roll in the efficiency of let down and the amount of air getting in.  There are so many organizations out there to support; you definitely do not need to battle this one out on your own, especially if feeding is currently uncomfortable!  A lactation consultant should also be able to help you check for tethered oral tissues (lip and tongue ties) that can be a culprit as well.
  • Clean up your diet.  Worst case scenario, even if you baby is not having any food reactivities, we get you eating healthier.

This was meant to be a quickly, but obviously I had a little too much to say. I hope it helps.  Having worked with dozens of families with stressed out little ones and sleep deprived moms, I can confirm that the struggle is real and that you are not alone.  You do not need to power through it or go it alone.  You have options to help support your baby’s most thriving health experience and set them up for success for the years to come (and get a little more sleep in the mean time).  Listen to you mama (or dada or gogo or whoever-you-are) intuition. You know your little one better than anyone else.  And don’t be afraid to seek support.

Happy feeding!

 

Resources & References

Bavishi, C. and DuPont, H. L. (2011), Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection. Alimentary Pharmacology & Therapeutics, 34: 1269–1281.

Mullin et al. (2008), Esomeprazole induces upper gastrointestinal tract transmucosal permeability increase. Alimentary Pharmacology & Therapeutics, 28: 1317–1325.

Dial et al. (2005), Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA, 294(23): 2989-95.

Ruskin et al. (2002), Vitamin B12) deficiency associated with histamine-2-receptor antagonist and a proton-pump inhibitor. Ann Pharmacother, 36(5): 812-6.

Rudolf et al. (2001), Guidelines for Evaluation and Treatment of Gastroesophageal Reflux in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. Journal of Pediatric Gastroenterology & Nutrition, 33: S1-S31.

Vagnini F, Fox B. The Side Effects Bible. Broadw ay Books: New York, 2005. p.311-312.

van der Pol et al. (2014), Efficacy and safety of histamine-2 receptor antagonists. JAMA Pediatr, 168(10): 947-54.

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