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Does my premature baby have reflux?

By Heather Cresswell, NP

What is gastroesophageal reflux?

The word reflux refers to any liquid in the body that is moving backward.

Gastroesophageal reflux (GER) is when liquid from the stomach moves into the esophagus (the tube that connects our mouth to the stomach). The liquid (often milk) may come out of the mouth as a spit-up or go right back into the stomach without anyone knowing it happened.


Sometimes we use other words for GER:

· Reflux (NICU teams will often use this shorter term to refer to GER)

· Regurgitation

· Spit-ups

· Emesis

· Wet burp


Why does reflux happen?

At the top of the stomach is a ring-shaped muscle called the lower esophageal sphincter.

Milk can flow backwards up the esophagus when:


· The sphincter relaxes at the wrong time (research tells us this happens many times each day in babies)

· The sphincter is not yet strong enough to stay closed properly


Experts think gastroesophageal reflux is "universal" in babies, meaning every baby has some GER. Milk will always follow the path of least resistance; sometimes, this will be "up."


Should I worry about my baby's reflux?

GER often bothers parents and caregivers more than babies. It is common for parents to feel worried, but GER is usually not a cause for alarm. Babies will outgrow reflux generally around the time they start eating solid food (sometimes a bit longer).


Your baby's doctor or team may talk to you if your baby has signs of gastroesophageal reflux disease (GERD). GERD is when babies have GER that causes troublesome symptoms. Some babies with other medical complications may also need help with their GERD (such as a history of needing surgery or genetic differences).


Some signs of GERD (with the added "D") are:

· Slow weight gain

· Signs of pain

· Difficulty with breast or bottle feeding because of pain or discomfort (turning head away from the nipple, arching back during feeds)


What if my baby is having "reflux-related spells"?

Sometimes, premature babies still in the NICU have a drop in their heart rate, breathing or oxygen levels (sometimes called a "spell") when milk flows backwards into the esophagus.

If your baby has "spells" thought to be related to reflux, these will go away as your baby matures. Your baby's team will make sure your baby is mature enough to cope with spit-ups or reflux without having a spell before you take your baby home.


What can we do to help reflux?

Time is the only thing that will eventually fix reflux (it will be outgrown over many months). However, there are some things you can do that might help improve your baby's reflux symptoms:

· Continue breastfeeding or provide breastmilk if that is part of your feeding plan.

· Give baby smaller, more frequent feeds.

· Hold your baby upright after feeds (chest to chest with legs straight down is a good position)

· Avoid putting your baby in a car seat or infant seat after feeds (any position that brings baby's legs closer to the stomach increases pressure on the stomach)


If your baby has troublesome GERD, your baby's team or doctor may talk to you about the following:

· Avoiding some foods if providing breastmilk or trying a different formula (some babies have trouble digesting cow's milk protein, causing symptoms that are much like GERD)

· Thickening feeds (usually not considered until babies are near or past their due date if they are feeding breastmilk as breastmilk)

· If your baby still has a feeding tube, the team may change feeding schedules or give feeds more slowly.

· Medicine is usually not recommended except in special circumstances.


Reflux at home

Rest assured that some spitting up is normal and expected for all babies. GER can look dramatic, especially if milk comes up through the nose and mouth. GER only means more laundry if your baby is eating well and gaining weight. So keep the burp cloths handy and remind yourself that all babies, premature or not, have some reflux, and the milk is just following the path of least resistance.


Seek immediate medical attention if:

· your baby ever has spit-up or emesis that looks green in colour

· your baby repeatedly has projectile vomiting (vomit that comes out with great force, often landing a few feet away on the floor)


Talk to your baby's doctor, nurse practitioner or team if:

· your baby is not gaining weight as expected

· baby seems uncomfortable with feeds (arches back and turns head away from the nipple after starting to feed).

· Your baby is not feeding well or does not want to eat.


Safe sleeping

It is essential to follow safe sleep guidelines, even if your baby has reflux.

Babies should sleep on their backs in an empty bassinet or crib (no loose blankets, clothes or toys). The mattress should be flat. Do not attempt to raise the head of the bed or use any positioning devices advertised to help reflux in babies.


Please review very important safe sleeping information here.

https://caringforkids.cps.ca/handouts/pregnancy-and-babies/safe_sleep_for_babies


Key Points:

· Almost every baby has some gastroesophageal reflux (GER)

· Babies will outgrow GER over many months. Your baby will be mature enough to cope with GER before leaving the NICU.

· Your baby's doctor or team will talk to you about options if your baby has signs of gastroesophageal reflux disease (with troublesome symptoms)

· Talk to your baby's doctor and ask questions if you are worried about GER or GERD.

· Always follow safe-sleeping guidelines.


Resources:

https://caringforkids.cps.ca/handouts/pregnancy-and-babies/gastroesophageal-reflux-disease-gerd

https://www.aboutkidshealth.ca/Article?contentid=817&language=English&hub=food&gclid=CjwKCAiAs8acBhA1EiwAgRFdw3rRSqTn8eG3s1vOBbwARvlO6aopaIl3GppoUPComgDvRY5tAhmbnRoCiQYQAvD_BwE&gclsrc=aw.ds


Heather Cresswell is a Neonatal Nurse Practitioner and health writer. As a nursing student in 1995, Heather discovered the NICU during a clinical placement and never looked back. She has spent her entire nursing career (more than 25 years and counting) caring for NICU patients (premature babies are her favourite!). When not caring for her tiny patients, Heather is also a health writer and is happy to contribute to the Canadian Premature Babies Foundation.

Heather lives in Burlington, Ontario, with her family and is a proud mom to one son.

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