REFLUX: Leading Expert Professor Shah Answers Your Questions Professor Neil Shah 7 May, 2019 Baby, Expert, Parenting We are here to talk reflux. If you’re baby is suffering, chances are you’re suffering too. If you’re reading this blurry or teary eyed, sleep deprived, depressed, or thinking of doing a midnight flit alone to some far flung country to get away from reflux hell, – step away from your passport. We were lucky enough to speak to the reflux doc everybody wants an appointment with. Professor Shah is Consultant Paediatric Gastroenterologist at Great Ormond Street Hospital, and has over 20 years experience in paediatric gastroenterology and a wide range of experience in most paediatric gastroenterology conditions. Dr Shah has taken some time out of his busy schedule to kindly answer some of our questions on reflux, to help you move forward in the right direction. What’s the difference between reflux, acid reflux and silent reflux, and what are the main symptoms of each? Reflux is the passage of stomach contents from the stomach into the gullet. If swallowed back down this is regurgitation. If you see regular milk contents or yellowy clear fluid this is vomit and a commonly used non medical term is silent reflux. Symptoms of silent reflux include back arching, screaming, irritability and being difficult to settle. It is really important to remember reflux is only a SYMPTOM not a diagnosis, so it’s vital not to just label a condition as reflux, but think of the underlying causes which can range from normal events to allergy, and occasionally, very rare and complex problems with the structure of the gut. A lot of parents I have spoken to have encountered the dreaded reflux. Why is it seemingly so common, and is this only a recent occurrence? This is a normal event in almost all babies and overlaps with colic. This can be a normal physiological event in the first six months of life, with normal symptoms typically improving dramatically from 12 weeks onwards. Often the persistence and non-settling of these babies despite simple measures is the worry or concern. What we are seeing more of, is screaming irritable babies which are more uncomfortable than normal, it’s then that they may have other underlying conditions. Is reflux more common for C-section babies or babies born under 40 weeks? Not reflux per se, but reflux/intense irritability that’s driven by allergies – mainly cows’ milk. Allergies in young babies are more common in C-section babies. Is gut bacteria linked to reflux? I.e. would infant probiotics help if given from birth, especially after a C-section? It’s definitely helped my baby’s wind, but not sure if it would be helpful for reflux. The answer is yes, there is a fundamental difference between the gut bugs seen in a baby born by C-section versus normal delivery and it is clear that probiotics is the way forward to help rectify this. The baby’s immune system is being exposed to adult versus baby bacteria and the baby’s immune system struggles to cope with this which can lead to allergic problems – it’s one of the hottest and most important topics in medicine at the moment and called the ‘microbiome’. Are there any developmental implications for reflux babies? My baby seems so preoccupied with her pain that her smiles are few and far between, her attention for rattles / any form of toys is minimal, and other babies of the same age seem much more interactive – is my baby missing those early milestones? I don’t think reflux has any implications, remembering the majority of reflux is self resolving and is the normal physiology or make up of babies, and has no impact on the major or minor developmental milestones in the long run. Reflux driven by allergies is more interesting as it is being associated with long term concerns like increased allergic disorders such as hay fever and asthma, tummy aches in school children and IBS in adults. Keeping baby upright has been advised after feeds – is it also correct to burp them in the usual manner, or is there anything I should be doing differently to try not to encourage the vomit that will usually follow anyway? No, this is this the standard accepted way to manage the problem. It’s also important to ensure there is an appropriate teat size for the bottle. Catnapping and snack feeding equates to massive sleep deprivation for all involved. Is there anything parents can do to help our reflux babies sleep better between feeds? The mechanism of small frequent feeds helps babies with reflux as it stretches the stomach less, creating less pressure build up and recoil of the stomach which leads to reflux. It seems a lot of parents have experienced a battle with their GPs to get the condition diagnosed and any medication prescribed. There seems to be a clear ladder of treatment from least effective to effective that we must climb (if we are lucky) to get the problem fully addressed. I was given a baby massage move by my GP in my first appointment on the matter. Why is the process so long and frustrating? This is a major issue and major problem. Reflux symptoms do overlap with many normal symptoms so it can be difficult for the GP with very short clinic appointments. Most of the simple medications except in simple cases don’t work in problematic babies and it is well recognised that more training and teaching is required but sadly resources in the NHS are very overstretched at the moment. It is recognised that many parents book multiple visits and undergo the ladder of treatments as you indicate. Delays in diagnosis are common, as are over and under treatments of reflux and underlying causes. My baby was initially prescribed 5ml liquid Omeprazole, which I’ve heard from some is the ultimate drug, and others that it’s not as good as Ranitidine. Can you tell me the differences between the two drugs in liquid form and the pros and cons of each? Does either medication decrease the volume of vomiting? Omeprazole seems to make my baby’s bottom wind so much more painful. Ranitidine is a histamine blocker and blocks acid but its antacid effect is short lived as you get used to it and the omeprazole is called a proton pump inhibitor and reduces acid secretion. Sadly there is no ultimate drug and many drugs are ineffective but and medicating should be done carefully with caution. What’s the difference between administering liquid Omeprazole, and the tablet form? Are there reasons that one might be prescribed over the other, or is it purely down to cost? The liquid form is easier to give and is made into a liquid by the addition of products called excipients. The tablet form is harder to dissolve. There is a huge cost difference and the majority are unlikely to get the liquid version READ MORE: Weaning Your CMPA baby – Things You Need To Know When can I expect my baby to ‘grow out’ of reflux? Is there a typical age, or is it completely different for each baby? We know after the first year of life, weaning onto solids and especially after 18 months to 3 years it’s much less common to see a baby reflux. I’ve read on more than one website forum that some parents have been advised to wean their child early, at around 4 months. Why does this help reflux and what are the drawbacks of weaning early in relation to reflux and their general gut health? The time to wean is an interesting topic and again, it is vital to know what the underlying cause is and identify this, e.g. milk allergy. There are pro and cons of weaning early and some evidence in egg and peanut allergy risks go down in high risk population so it’s a hotly debated topic. Weaning in reflux works by the fact that solids stretch the stomach less and the stomach is less likely to force its content through a valve at the lower end of the gullet which is immature and still developing. It’s about the stomach being stretched less and reflux less as a result. Fluids like milk are more likely to stretch your stomach. Is it true that cows’ milk intolerance goes hand in hand with reflux, and what are the additional symptoms to look out for? Yes, the milk allergy can definitely be a cause of reflux, and often milk allergic children display the following symptoms: inconsolable crying, change in stools, excessive straining, painful wind passage, nasal congestion, back arching, blood and mucus in the stools and be very unhappy. Often reflux will have multiple causes rather than vomiting alone, and a lot of persistent silent reflux can be a hidden milk allergy. Some mums have recommended Gaviscon for reflux – when is it appropriate to use this medication? I’ve heard it can make wind much worse, so perhaps not suitable for babies with reflux and CMPA? I don’t use it much at all as it constipates babies. I am sure it works well for some babies but on the whole although commonly prescribed for the children I see it does not work well. Neocate seems to be the formula that every parent wants to get their hands on. Why is this the Holy Grail for reflux sufferers? What are the differences between this and Nutramigen or other milks prescribed? Neocate is a tried and trusted formula but there are now others that work in a near identical fashion so there are other options. In the past there were none, so historically Neocate was and still is a good formula if used in the appropriate child. It should be prescribed carefully in babies with multiple un-resolving symptoms and persistent weight loss, symptoms that are not common – it is these cases that find these milks helpful. The majority will respond to milks like Nutramigen of which there are several types, but some may need Neocate type milks. I’ve read recent research conducted by Australian support website that 1 in 4 parents with reflux babies suffer from PND, and 1 in 5 no longer wish to have more children. What else can parents do to help their child, besides battle to get the diagnosis and medication needed? Yes, that’s true, we have completed two quality of life studies and reflux has an impact in the family unit and parents – especially the mother. Parents will find that not only their sleep is affected, but bonding with baby is too. PND is not uncommon; it can be very difficult for families and very distressing for them. Better recognition, appropriate treatment and changing milks can really help but simply listening and not dismissing the parents outright is key, we must have an understanding that there may be a real problem, and listening is probably better than prescribing a medication that probably has very little benefit in working. Dr Shah can be contacted for appointments via Ms Rubi Begum at The Portland Hospital 215 Great Portland Street LONDON W1W 5PN on 0755 442 8969.