My husband’s family lineage has inflammatory bowel disease (IBD): Crohn’s, celiac, diverticulitis, pancreatitis. Recently a family member landed in the hospital with a severe bout. She was in for a week, clear liquids, IV fluids and antibiotics, and sent home. No one spoke to her about food, other than to go ahead and eat a lot of fiber from grains.
Within no time, she was in severe pain again, tolerating only clear liquids, and back to her GI specialist. After lots of poking and prodding, same advice: Go home, eat what you want. Fiber? Sure, that too.
Many infants, toddlers, and older children in my practice have been down this road too. Some have necrotizing enterocolitis, fundoplication, or feeding tubes inserted into their stomachs or upper small intestines. Others have newly diagnosed celiac, FPIES, or even Crohn’s at a young age. These conditions are deeply linked to what you eat and to what grows in your gut biome. But it’s common for the healing potential of food and “good gut bugs”to be overlooked by well meaning GI specialists. Research is rapidly expanding in these areas. But it’s not yet standard-of-care for people with painful IBD conditions to get much detailed guidance on foods and gut microbes. What you eat isn’t a GI doctor’s gig; some might choose to work closely with you on it, some might suggest or even prescribe a probiotic, some may refer you to a nutritionist or dietitian. But most are choosing whether or not you need surgery, steroids, or other drugs.
There is much that can be done beyond the prescriptions and surgeries. Check with your specialist on the recommendations I suggest here before using them. Your gut may be able to heal up (and you may avoid having a section of it removed) with some TLC, supportive eating, and some nourishing, soothing herbs. I’ve seen it happen many times in vulnerable children and infants I’ve worked with. You need and deserve to feel better – I know you’re a busy person!
1 – The common advice to eat high fiber grains after an IBD flare up is, well, bad. You might actually take some comfort in knowing that it is not surprising that those may worsen your tender condition. Grains are possibly the toughest stuff to feed an injured and inflamed gut. My usual approach in tender situations like this with vulnerable children and infants is the opposite: NO grains at all for a while. That would mean no bread, rice, pasta, pastries, bagels, toast and so on; no gluten free grains either, including rice, barley, spelt, millet, oats or oatmeal, cous cous, quinoa (not a grain technically but similar), corn (including corn starch, corn syrup or high fructose corn syrup, which is in many processed foods), and teff. No white bread, no bread, period. I usually advise avoiding all grains for a long time, at least three months, for scenarios like this. Your carbs in this scenario become certain cooked vegetables and some fruits. See below on how to introduce those, and which ones are okay. Meanwhile you can use broths (see number 2) and fats to hold you over.
2 – Broths are a good idea. But there’s not-so-great broth (store bought in a box, can, or a dehydrated cube, with MSG, gluten, corn starch, or wheat flour, additives, and little nutritional value) and then there is really good broth (homemade or special order homemade, full of minerals and helpful satiating fats)! If you happen to have vegetable scraps around and a chicken carcass leftover from a roast chicken, set those on the stove for a day or two, cover with water, add some vinegar (about a half teaspoon) or some white wine (1/4 cup) to pull the minerals out of the bones. Let everything cook until disintegrated and soft. Add water if needed as you go. Add herbs (fresh sprigs of sage and rosemary), throw in a whole chopped lemon, and 3-4 cloves of garlic. Strain this and enjoy as often as you like. It’s more nourishing and restorative that the stuff in the can, and is grain free (even tiny amounts of wheat starch might be irritating). Leave the fat in the broth, or skim off only some of it. You can use ham bones or any bones left over to make a broth, if it simmers long enough. If you like, you can even order this luscious, real bone and vegetable broth on line – you’ll find it is heartier and more satisfying than the store stuff.
Starting a vegetable broth – scraps are perfect too
3 – If you’re on a clear diet (clear fluids only), some foods may still be okay for you and I have seen this work in my practice too. Certain vegetables and fruits cooked soft that are easier to digest (because they have simpler, smaller, less fibrous carbohydrate in them) are where I would start. You can find a list of those that fit this criteria here: http://www.breakingtheviciouscycle.info/legal/listing/ Any food that is “legal” on this list worth a try. Clear foods that may be more harm, and do you no good: Store bought juices with corn syrup or sugar added, broths processed with additives as mentioned above, clear jello, or any processed, artificially colored and flavored “food”. Some veggies that you might not enjoy so much right now are the brassicas: Broccoli, cauliflower, Brussel sprouts; cabbages; or most any raw vegetable. Even well cooked, these may not feel good just yet. If you crave greens, enjoy them well cooked and not raw for now, if at all, until your IBD flare settles down.
4 – Meats, poultry, fish: These are very possibly okay even for a tender gut. Watch how you respond. They are very nourishing, so include whatever feels okay. Start with white soft cooked fish like tilapia or cod, without any bread coating; you can brush with coconut oil, ghee or olive oil or butter, garlic, lemon, and as much salt as you are currently allowed to use. For some, salt does not impact blood pressure, so use your usual amount – and use good culinary salt (sea salt or Himalayan salt, not plain old Morton’s type sodium chloride). The better salt has more minerals in it, which your gut needs to heal up. Next you might advance to some really good, organic, slow cooked, tender roast of beef, done in perhaps a crock pot or slow cooker so the juices stay in and keep it moist. Cook it to the point of just falling apart, soft enough for a fork to cut through. Roast chicken may also be okay, with skin. We often make a crock pot recipe that is easy (we skip the aluminum foil in the recipe, and add a whole lemon or two, some onions, and extra garlic chunks). Again the meat should be very tender and falling off the bone, juicy and moist. Roast pork, same thing, if it can be cooked long enough to be falling-apart tender. Avoid barbecue sauces until you feel better (usually they have gluten, grains, or other harder to digest additives). Avoid bread coatings, or gravies made with thickeners like corn starch, any flours (even gluten free), or arrowroot.
5 – Even if you are already using a probiotic, a prescription probiotic called VSL-3 is often beneficial and preferable for these situations. See if your specialist would agree. Don’t bother with the store bought stuff. Not worth it, may contain irritating additives, and the potency is so low as to be of no value in circumstances like progressed IBD. You might alternatively benefit from VSL-3 capsules, which are available without prescription. The prescribed version is a sachet of powder that mixes with soft food or liquid. It has a very high potency of 900 billion CFUs per dose of mixed strain beneficial microbes. The capsules are the same formulation except lower potency (180 billion CFU each), and without the maltodextrin. Caveat: If you have a condition called small intestine bacterial overgrowth (SIBO), probiotics may cause more pain and diarrhea. Check with your specialist about ruling out SIBO before using a high potency probiotic like VSL3. SIBO may need treatment first, before probiotics will be helpful. In my office, Dr. Jill Carnahan and I use a urine microbial organic acid test as well as stool tests to assess this.
6 – Use daily gut soothers: Peppermint tea, chamomile tea, or a blend of those. Other herbal helpers include slippery elm, ginger (fresh root), licorice (added benefit for some of lowering blood pressure), and you can use tinctures or teas. Skip capsules at first if you can, to give your gut one less thing to do (digest the capsule before getting to what’s inside). Glycerite tinctures are especially gentle and absorbable, versus alcohol blends. Meanwhile, another really good soother and healer for the gut is pure aloe juice. This is available at most better supermarkets or health food stores. Buy pure organic aloe juice – not the topical preparation, but the juice for oral consumption. Use 1-2 Tablespoons daily in water. Also eases any constipation if you have it. Avoiding all caffeine sources may help.
Yummy green smoothie
7 – Juices can help too – but not the store bought corn syrup stuff. We’re talking fresh juices you make at home. To make nourishing, easy to digest, healing juices, you need a powerful juicer machine that strains things (not a macerator juicer, but one with a strainer). Try what feels good, and your intuition may surprise you with its own skill! Some of my favorites are here. A good combination for a sore gut:
– 1-2 Delicious apples
– 1 inch peeled fresh raw ginger
– 5 stalks celery
– some sprigs of fresh mint or basil leaves
Your juicer should strain this while it juices. When you feel a little better, you can add ½ a small whole lemon to this blend. This is soothing for liver, kidney, and digestion. As for heartier greens like kale or chard, initially, searing those and eating them cooked, especially with healthy oils like coconut or sesame, will feel more soothing at first. Straining and drinking them raw can work better later on.
Juicing underway with a centrifugal strainer type of juicer by Breville.
8 – You can temporarily use a supplement for ready-to-absorb protein, in case eating protein from whole food is painful. This is important because you need protein to build healthy gut tissue. If eating meats, poultry, eggs, or fish just does not work, I lean on specialized supplemental formulas in my practice. There are some available by prescription and some that are over the counter. These can help keep you replenished and give your gut something to rebuild with. I generally don’t reach for protein supplements based on dairy, soy, or rice, since so many of my patients have trouble tolerating them. Hemp protein may also be harder to use at first in a tender gut. When all else fails, I work with prescription essential amino acid mixtures from SHS North America. Some do well with whey protein that is from organic, grass fed cows and not denatured; I will order a specific brand that meets those criteria in some cases. Lastly, a supplement called Galactommune often helps my patients recover gut function more quickly, as it helps build immune boosting globulins in the gut. This can be ordered directly from its manufacturer with code 825.
9 – Fats and oils: These are healthful and important for you while you eat a limited diet. They keep hunger at bay, transport and absorb certain nutrients and vitamins into tissues and cells, and cut inflammation (when you eat the good fats). Eat what feels comfortable, from least processed sources if possible. That means butter, ghee, coconut oil (for cooking), eggs (if you find them comfortable), olive oil, bacon (if easy on you), meats, and fish. Fats to avoid are margarines, fake fats, canola oil, corn oil, soy bean oil, processed cheeses, dairy desserts with lots of corn syrup, highly processed puddings or calorie boost drinks, or anything GMO. Go organic if possible, since fats and oils are where many toxins situate in plants and animal foods. Nuts and seeds or their butters, a good source of minerals, proteins, and fats, may not be tolerable yet. Long short: Fake fat and low fat is not going to help your body. For a gentle soother, try cooking a soft scrambled egg in a tablespoon of coconut oil. Mix the egg and oil briskly with a whisk for about a minute. Coconut oil is easier to break down than most other fats and can work to calm an irritated gut wall.
10 – If you use a reflux medication on a regular basis, ask your specialist how to stop. Reflux medicine, when used too much, weakens digestion and makes it harder for beneficial gut bacteria to grow. Beneficial bacteria support your gut wall in avoiding autoimmune storms and infections. Meanwhile reflux medicine makes it easier for damaging, detrimental gut bacteria to grow. Minerals, including calcium, zinc, and iron, are harder to absorb in this context. Some studies have shown that long term use of reflux meds in elderly people means more broken bones. I have a number of young patients with delayed bone age and stunting who were given reflux medications from birth. These are over prescribed. If you use one daily and stopping is painful, there is a simple strategy to wean off slowly: Begin using raw apple cider vinegar (such as Bragg’s brand) daily in a glass of water. Use about a half teaspoon. You can do this at each meal, or only when you feel reflux or heartburn. This will gently promote normal digestion. A more aggressive strategy is to use betaine hydrochloride capsules, and swallow 1 to 3 of these with meals. As many as 6 or 7 capsules of betaine hydrochloride are safe to use at a time, but no more. You will know your limit if using these triggers a burning sensation at top of stomach. Find your comfortable dose. It may be just one capsule, it may be four; use only what you need. Note any changes (good or bad) in demeanor, behavior, anxiety, or affect too: Gut ecology has been linked to shifts in what we categorize as psychiatric disorders.
Have a conversation with your specialist and see what s/he says. Remember: Their tools are antibiotics, antiviral medications, steroids to stop inflammation, reflux medications, and surgery. All these have a place, but none of them are food. Food is what your body needs to rebuild, even as you use the specialist’s tools. If all the juicing and cooking is overwhelming while you are managing your symptoms, consider a home health aid or someone who might come in your home for two hours a day to help out. A week or two of help can pay itself back in quickening your return to health, if you are debilitated by symptoms or just had surgery. Meanwhile there are many, many supplements that are often used to help a gut heal too. But, food is still the baseline, and it’s what your body will work with to rebuild, recover, and heal.
Lots of babies start life with spit up, colic, crying, and weird poop. What’s normal? When do you get help? When do you let it roll? Does your baby need medication for reflux and poop? How are they related?
First, some context: Reflux in babies only started to get a lot of attention when industry began making drugs for it. During the late 1980s, omeprazole (Prilosec) became the first proton pump inhibitor (PPI) reflux medicine to hit the market. It wasn’t FDA approved for babies and kids, and it wouldn’t be for 20 more years, in 2008.
Before then, “reflux” medicines were called “antacids”. They were sold as over the counter medicines. Products like Maalox (aluminum or magnesium hydroxides that bind stomach acid) or TUMS (calcium carbonate) are examples. Antacids were marketed to adults; giving them to babies was generally unheard of. Enter omeprazole – which stops the stomach from producing acid in the first place – acid that is crucial for digestion, and for the absorption of protein, minerals, and B vitamins.
In 2008, omeprazole finally got FDA approval for use in children. Not coincidentally, this was also when its original patent was challenged by generic drug makers who wanted in on the profits. If the patent was to expire, Prilosec maker Astra Zeneca certainly had a motivation to secure exclusivity for the pediatric market. Even then it was only approved for kids over a year old – that is, toddlers and kids – not babies, who are less than a year old.
Approval in kids was granted for “short term treatment up to six weeks for a diagnosis erosive esophagitis”. Only one PPI medication – esomeprazole (Nexium) – became FDA approved for babies age 1 year (12 months) or less, also only for short term, for diagnosed erosive esophagitis.
Erosive esophagitis (EE) – also called corrosive esophagitis – or eosinophilic esophagitis (EoE) – require an endoscopy to diagnose. But in my pediatric nutrition practice, I routinely meet babies and toddlers who have never had endoscopy or any other work up to check for these conditions – and they are placed on reflux drugs like Prilosec anyway, for months, or even years, after a brief chat with the pediatrician. PPI drugs shot to popularity for babies even before they were approved for use in that age group.
Pediatricians were using them “off-label” – that is, outside of FDA approval. Starting in the late 1990s, it was all-systems-go for marketing the idea that colic, spit up, or vomiting in babies were “diseases” – aka “reflux” or “GERD” – that need treatment. Both pediatricians and parents got the marketing push: Not coincidentally – again – in the mid 1990s, rules for “direct-to-consumer” advertising were relaxed. Money poured into media for prescription drug ads, whereas before, only over-the-counter medicines were allowed on TV and media (think aspirin, Pepto-Bismol, Metamucil, Midol, or …Maalox).
As the floodgates opened to promote prescription (“ask your doctor about…”) drugs on TV and other media, the pharmaceutical industry was free to essentially invent diseases to promote their products. The phrase “acid reflux” became one of those “diseases”, and PPIs became one of the most over-prescribed drugs for babies. “Acid reflux” itself requires an invasive pH probe procedure to diagnose – but again, I’ve met countless babies and kids who had no work up done, but were diagnosed and given reflux medicines anyway.
So, the answer is this: Spit up, vomiting, and colicky features are normal for babies, especially in the first few months. Somewhere between 40% and 70% of young infants will spit up or vomit on a daily basis, and still thrive.
There are a couple of reasons for this. One, their stomachs don’t yet produce enough acid to tackle feedings very well. Eventually, this comes on line, typically by about age six to eight months. Once there is enough acid in stomach to meet the food going in, it can take it apart pretty quickly and send it on to the intestine for further digestion. If acid in the stomach is too weak, food (breastmilk, formula, first foods) will …just sit there. The longer a feeding sits there, the more it can go backwards, up into the esophagus. No matter how weak a stomach’s acid is, it’s still too acid for the esophagus, where it can burn and hurt when it goes backwards.
It’s easy to see how putting a strong acid suppressant like Prilosec into this mix will not end well. Parents often report to me that their babies seem to need more, more, and more of this medicine to control reflux over time. No wonder! This creates a downward spiral of less, less, and less digestion which allows feedings to sit in stomach longer, longer, and longer. It makes sense to use this strategy only if there is corrosive tissue damage to the esophagus that must be stopped – just as the FDA decided.
The other reason why spit up and vomiting are normal at first is that babies’ stomachs are so tiny compared to the volume of feedings they need to grow so fast. By comparison, a five year old’s stomach capacity is much greater, while their velocity for growth and gain has settled down. At birth, a baby’s stomach capacity is only about two teaspoons, while per-pound needs for energy and nutrients are two to three times higher than a sibling who is five years old. A baby’s growth velocity is absolutely huge! By about age ten days, a baby’s stomach can still only manage about two ounces (~two Tablespoons) at a time.
Meanwhile, babies have a short esophagus and underdeveloped control of the sphincter between the stomach and esophagus, so it’s easier for feedings to go “backwards”. This is why small frequent feedings and sleeping a bit upright are helpful for stomach acid early on. The frequent feedings keep stomach acid a bit neutralized, and the small size of feedings is manageable.
Misery, hard lengthy crying (more than two hours/day), endless hiccups, arching with crying, pulling away from feedings, difficulty getting enough sleep, and weak growth pattern are signs that your baby might need some fixes to make digestion easier – but a PPI drug acid suppressant isn’t necessarily the answer. Frequent small feedings, upright or slanted position for sleeping, changes in formula choice or diet choices for breastfeeding moms, or gentle digestive bitters drops for babies like this Tummy Glycerite may do the trick. You can find Tummy Glycerite along with other tools I use in my pediatric nutrition practice in my dispensary here. Check with your doctor before using supplements.
That’s a quick primer on reflux in babies. What about baby poop?
Babies, like everybody else, ideally will move their bowels daily. Stool that sits in the intestine and colon for too long permits toxins to flow back into circulation, and these can be irritating to mood, behavior or sleep. This can also feel painful or uncomfortable, or diminish your baby’s appetite. Stool that passes too fast will carry too much fluid out with it; nutrients, energy, and water won’t be adequately absorbed.
More than anyone else, babies are quite sensitive to these dilemmas. Occasional changes in this pattern are of no consequence; persisting patterns are. This is common sense as much as it is sensible nutrition science!
Many things disrupt stooling for babies. Teething, stress, immunizations, antibiotics, food intolerances, and infections or illnesses can all cause changes in stooling pattern, but the changes should be temporary for your baby. Even if your baby has special needs or circumstances, make restoration of comfortable digestion a priority. On balance, your baby should comfortably pass formed soft stools every day – as many as four or six mushy stools in young breast fed babies – and it shouldn’t smell exceedingly foul, be foamy, or contain a lot of mucus. Breast-fed infants have softer, mushier, wetter stools that look more seedy and light brown or gold, and these babies may pass stools more often. Younger babies may also have more frequent stools. Formula fed babies who are digesting well will often have more formed, more brown stool that is passed without much fanfare or distress.
Here are tips that something is off – especially if any of these persist for more than two or three weeks with no explanation. Think about making a plan to correct it, so your baby can absorb all the nutrition he needs to grow, sleep, play, observe, learn, and thrive.
More than 5 or 6 stools per day
Fewer than 3 or 4 stools per week
No stools passed for more than three days on a regular basis
Liquid, runny, or watery stools
Mucus in stools (gobs or sheets that look like raw egg white)
Clumps of congealed or fluffy white material (typical of a Candida/intestinal thrush)
Undigested, whole pieces of food in stools that persist over weeks
Stools that are explosive or overflow onto your baby’s back or neck
Yellow, gold, tan, pale gray, black, or green stools (dark mustard colored stools are normal for breast fed infants)
Hard, dry, pebble-like stool that appears painful or difficult to pass
Plugs of hard stool followed by explosive loose stool
Unusually foul-smelling stools
Can probiotics help?
Probiotics may restore a healthy stool pattern. This is a signal that digestion is working properly, and that the baby’s immune system is working in partnership with important helper gut microbes. I use them often in my pediatric nutrition practice, and choose from different brands and formulations based on a child’s needs. Review these options with your doctor. If good to go, you can set up your own access to any of these products in my practice dispensary and easily order from one source, here.
Try a bifidobacterium blend probiotic powder in your baby’s feeding once a day. Bifidobacteria are the most abundant strains in the guts of healthy infants, where they help support the immune system. For older babies (over six months old), my product preference is HMF Bifido Powder. I begin with a pinch of powder and gradually increase to 1 scoop daily (20 billion colony forming units or CFUs) if comfortably tolerated. For younger infants, my preference is ProBiota Bifido, for its lower potency and exclusion of the potato starch. Though the potato ingredient is great as a prebiotic, younger infants may not tolerate it yet.
Stop if you notice explosive diarrhea, hives, fever, more gas or discomfort, projectile vomiting, or sudden rashes.
Look for Bifido strains such as B. breve, B. infantis, B. longum, and B, bifidum in the product, and a potency of at least 8 billion CFUs per dose.
Safe Lactobacillus strains that can be added for babies nearing their first birthday or for toddlers are L. rhamnosus, L. casei, L. paracasei, L. gasseri, L. reuteri, and L. salvarius. My product preference in that case is ProBiota Infant Powder. Again, start with only a pinch and work up to a scoop daily in soft foods or liquids. Some toddlers may need as many as 4 scoops daily to restore a healthy stooling pattern – but if discomfort ensues, reduce dose.
Don’t use L. acidophilus in babies, premies, or infants with necrotizing enterocolitis (NEC). The form of lactic acid made by this species appears to be tolerated poorly in babies. In fact, one study showed that it actually increased allergy (noted as skin rashes) in babies.
Probiotic powder can be blended with soft food, breast milk, or formula. You can also dust some on the nipple of the bottle or the breast. Don’t microwave, freeze, heat or cook probiotics. Store in fridge.
Babies with a lot of gas and reflux may need a simple product with just a few strains, rather than a multi strain product. For young infants, I often reach for Factor 4; for older babies and kids, I often choose this Lactobacillus blend.
Don’t give probiotics at the same time as an antibiotic. The antibiotic will kill the probiotic. Wait until the course of antibiotic is completed, then begin using a probiotic daily.
If your baby must use antibiotics for longer than two weeks or indefinitely, you can add probiotics at the opposite end of the day. For example, if an antibiotic is given in the morning, give the probiotics in the afternoon or evening.
How are reflux and baby poop connected?
What does poop have to do with reflux? Essentially, the same things that can trigger some backflow into the esophagus can disrupt stool pattern too. Remember that some “reflux” – which simply means some food goes backwards into the esophagus – is not a disease, and is normal for babies. If your baby is growing well, sleeping well, doesn’t cry excessively, and has comfortable stools, then all good. Some hiccups, burping, crying or fussing is normal.
Goat milk formulas like this one are available. Roughly half of babies with cow milk protein allergy can tolerate goat milk formula.
That said, unresolved and chronic vomiting (such as is seen with FPIES), diarrhea, constipation, and misery are not necessarily benign for a baby. For a young infant, crying takes a lot of energy – like a heavy gym workout for you or me. Crying hard for more than 2 or 3 hours every day is costly enough to impair growth and may even harm the baby’s brain. Along with weird poop or prolonged, vigorous hiccups or vomiting, it can signal malabsorption, pain, imbalanced bowel microflora, inflammation, infection, milk protein intolerance or allergy, or any combination of these.
The solution: First, determine if your baby needs any intervention at all. If they do, then fix the root of the problem, rather than mask it with an acid suppressing drug. This can help both the colicky symptoms that look like reflux, and settle down stooling patterns – so babies can eat, digest, and sleep more comfortably.
Here’s how it looks when too much reflux medication has been used: One child I worked with was given reflux medication daily for the first three years of his life. Though he had been off this medication for three years by the time I met him at age six, he was stunted with delayed bone age. He had poor bone mineralization, growth failure, and developmental and learning problems. His appetite was poor. He was painfully constipated with dry hard stool, despite drinking plenty of water. He was unable to eat enough to sustain normal growth since eating was so uncomfortable. He’d had chronic infections as an infant and toddler, needed antibiotics often, and became asthmatic as well. Reflux medicine had arrested normal digestion for him, for years – and he had paid a heavy price.
Over time, acid-suppressing drugs like omeprazole alter gut microbes – and not in a good way. They engender overgrowth of toxin producing microbes like Closidtrium difficile (C diff), Helicobacter pylori, or fungal strains. By promoting a dysbiotic microbiome, PPIs can cause irritable bowel syndrome or constipation, reduce microbiome diversity, and encourage inflammation. Using these drugs in infants – for the wrong reasons or for too long – means missing the critical window we need to establish a beneficial gut microbiome in the first three years of life. We rely on this microbiome to prevent allergy and asthma later on. Studies are already emerging to show that PPI use increases asthma risk in children.
Your baby gets to thrive and be healthy! We are learning more every year about how establishing a healthy gut microbiome early in life helps digestion, appetite, eliminations, and immune function for years going forward. Natural supports for these are widely available. Visit my online dispensary to browse and view protocols that I have created for use in my pediatric nutrition practice. Thanks for stopping by!
