Reflux in babies not a “disease”
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.
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!