The truth is that diagnosing reflux is REALLY hard to do. Don’t believe me? You probably shouldn’t, I’m not a pediatrician.
Which is why I asked our beloved pediatrician, Dr. Steve Hale of Essex Pediatrics (Essex, VT) to weigh in on the subject. And for some mysterious reason he agreed.
From the Desk of Dr. Hale
Dr. Hale larger than pictured here.
As a practicing pediatrician, when a get a call from a parent wondering if their baby has reflux, my first thought is to make sure there isn’t something else going on. Reflux seems to be an “in” diagnosis currently and I don’t want to miss something more important. So I will ask the parents to bring in their baby to rule out any other problems. I’m looking most importantly for a good weight gain. Adequate weight gain in the first few months makes me feel more confident that there isn’t a concerning illness lurking.
If, after checking out the infant I’m confident there is not a troublesome medical problem going on because the exam, weight gain and history are reassuring, then I am left with a crying, screaming, healthy baby and exhausted, frustrated, end of their rope parents!
The question is, could this be reflux? My baby eats and is growing but seems uncomfortable, arches, screams, and is always irritable. In those moments he/she is not doing these things they are adorable and meeting all their developmental milestones. The only problem is the only time they are happy is when someone else is watching them or of course when you come to the doctor and they are perfect for the 30 minutes you are there.
The answer is, of course it can be reflux, because all babies reflux. Gastroesophageal reflux is simply fluid from the stomach coming up into the esophagus which happens around 30 times a day for most infants. If it comes out of their mouth it is spitting or vomiting. The peak age of reflux is 4 months and most kids stop spitting up by 18 months of age. We all reflux daily throughout our lives.
Gastroesophageal Reflux Disease?
Gastroesophageal reflux disease is what they call it if the reflux causes symptoms that are a problem. And here is where it gets tricky. All the experts agree that infants reflux but studies are unclear when, if ever, it causes problems. When they record episodes of reflux using an esophageal pH probe, the episodes don’t always correlate with when the baby is crying and unhappy. So there is no convincing medical research that says yes, your arching, crying, screaming baby is doing all that because of reflux. Even worse, studies on treatment of suspected reflux don’t show that medication is helpful. But meds are used all the time for reflux you say! You are right and that is because we are desperate to help these exhausted parents, and some time it does seem to help but the evidence is not scientifically strong.
The pediatric literature in the last several years has had big studies showing meds don’t help reflux and pushing us primary pediatricians to use less medicine. The big conclusion is that reflux does not equal pain.
So back to the exam room with the screaming baby and crying mom, what do I do. Well, what I do is born out of my experience and my reading of the literature and may be different from my partners. I am constantly reevaluating and trying to figure out for each family what is going to work best.
Reflux Management Strategies
I start with safe interventions that might help. Positioning the baby on their stomach at about a 30 degree angle is the least pressure on the stomach and does decrease reflux. We don’t let them go to sleep like that though because sleeping on their back is safest to prevent SIDS.
Thickening feeds helps for those kids who are bottle fed as it is heavier and takes more force for food to come out of the stomach. We then will try things we use for colic ( which is virtually indistinguishable from reflux ), such as having mom eliminate dairy from her diet if she is nursing, trying infant gas drops, trying hypoallergenic formula for those babies being formula fed. I usually try to make one change at a time and try it for several days to see if it works and because I know this is going to get better eventually whatever we do, so if I space things out maybe it will miraculously go away. I am praying desperately during this time that the baby improves because I am running out of options and prayer seems to work as well as anything else!
When to Try Reflux Medication?
If nothing is working then I will have a conversation with the parents about reflux medications, stating they haven’t been proven to help but some infants seem to really improve and they seem safe in infants. If they choose to try that route, I usually give it 1-2 weeks to see if it helps and I tell parents it should be a dramatic improvement if it is really helping. I don’t have a great justification for this except I am convinced about the safety of the medications and I think the potential benefit of helping the baby and the parents outweigh the lack of scientific data about its usefulness
I do this on a family by family basis. Every family is unique which is what I love about my job. So I will have one mom happily tell me her baby is great and only cries for 4-5 hours at night, and another mom tell me her baby is wearing her out because she has to get up once during the night for 15 minutes for a feeding. Every parent brings their own history, childhood, temperament, issues, neurosis, genetics, angst, and love to the job of parenting, myself included. My job is to try to find out how to help each parent be successful and fulfilled as a parent so their child can be successful and loved as well. And reflux and its issues is one of my biggest challenges.
Steve Hale, MD
OK, please show Dr. Hale some comment love for taking some time to help shine some light on the challenges of diagnosing reflux. Thanks!
{Photo credit: Kennie Louie and Pat David}
Linda on 
Laura on 
I love how you say you spread it all out hoping it will go away on it’s own.
Thank you so much for your time in writing this!
Our former pediatrician prescribed meds anytime you mentioned the baby was spitting up. We didn’t know better so just filled it and medicated all 3 of our children without trying anything else first (or tried changing them all at the same time). Pretty sure baby#1 was just over-tired. And babies #2 and #3 were just spitters and didn’t seem hurt by it. I’m glad to have found a new pediatrician who isn’t so quick to prescribe medicine.
Dr. Karp says that 25% of US babies are treated for reflux when only 2% actually have it. So you weren’t the only one who had meds pushed on you when you might not have needed them. Hmmm….does that make you feel any better?!?
Alexis recently posted..What to Do About Infant Reflux?
Great and very moderately tempered article. Our first child had reflux. We were going to the pediatrician every single week desperately looking for answers – one week, I actually keep an obsessive spreadsheet of exactly when he cried during the day to make sure my concerns weren’t just a first mom thing. Our pediatrician told us that up to about 4 hours of crying a day was normal at his age, so when I tracked it and learned he cried more than that, it was at least informative. I appreciated that, like you, our pediatrician was calm, reassuring, and never allowed us to pressure him into medication as a first line of action. I think he probably sensed that we wanted the problem solved ASAP, but also wanted to avoid medications if we could. In addition to the measures you mentioned, he also had us prop our child up at a 45 degree angle swaddled tightly when sleeping. (I think we had him like that most of the day!). Ultimately, when our child was only sleeping 45 minutes at a time at night, he sent us to get a Barium swallow. Not sure if they do that anymore, but they diagnosed the reflux based on that. Thanks for the good article – very helpful, especially for first-time parents.
Kid Id recently posted..My Son, the Party Planner
I’m impressed that you were able to take your time considering medication. When the idea of reflux was first suggested to us we JUMPED on medication out of sheer desperation. Of course it was pretty obvious that we had hit on something because the change was remarkable. Our inconsolable non-sleeping 5 month old turned into this cute happy baby. Hazzah!
Alexis recently posted..A Pediatrician Weighs in on Infant Reflux
Oh, a soon as it was prescribed, we jumped at the chance too – it was our pediatrician that took his time being cautious for us. And we appreciate that now – perhaps not before : )
Kid Id recently posted..My Son, the Party Planner
My newborn (my first) has been diagnosed with reflux and this is the best article I’ve read about it. I like the distinction between reflux and GERD. A very well balanced explanation, thank you.
Good luck and welcome to the reflux survivors club!
Alexis recently posted..What to Do About Infant Reflux?
Excellent article, thank you very much Dr. Hale!
Hear hear! Unfortunately for the rest of the doctors I know I’m now feeling emboldened about hassling other members of the medical community to come share here
Alexis recently posted..What to Do About Infant Reflux?
As much as I wanted to avoid meds, my 6 month old son is a different kid on Prevacid. I tried all of the non-medication solutions but he was just uncomfortable and gagging non-stop (holding his breath, too) till we got him on meds. He never spit up, he just arched in (apparent) pain. We ended up doing an upper GI (barium swallow) to rule out any anatomy issues and confirm the reflux. My son also has food intolerances (via my breastmilk): dairy, soy, corn, wheat, nuts. Not fun. He’s my second kid and my first also had similar food intolerances (but no GERD).
What I have been desperately wondering is, why so many more kids seem to be having these issues? My mom’s generation of moms never thought about milk protein intolerance issues and my dad, who did a pediatric rotation in med school, never dealt with that or reflux/GERD. Now it seems that almost all of my mom friends are dealing with one or the other or both.
I hope someday we know why – maybe too many pesticides in our food? too many antibiotics prescribed? to much antibacterial everything?
Sorry for the tangent – just thinking about it a lot lately.
Thanks for a great article – good guidelines for managing reflux without medication and very nice to read the part about how each family needs to be treated differently – love that.
I have been wondering the same thing, Sandia! My mom was completely shocked when I told her I thought LO had reflux during those early “colicky” weeks. She told me our generation has too much information available via the internet and we will drive ourselves crazy with it. I tend to agree but that doesn’t stop me from googling every single little thing LO does hahaha.
I agree with her about the googling thing. Sometimes ignorance really is bliss
Alexis recently posted..What to Do About Infant Reflux?
Dear God woman, how did you figure out that list of food intolerance? Going dairy-free is pretty straight forward but cutting out soy, corn, wheat, etc. is pretty intense. Well I guess the upside is that now your diet must be uber-healthy?
As to why this never used to happen…the common opinion seems to be that all reflux babies were just viewed as having colic. And as most babies outgrow reflux by 1, if you had a refluxing baby, people just thought you had a really bad case of colic.
As for the food allergies/intolerance, I believe the most popular explanation is the hygiene theory. Prior to ~100 years or so we all lived hand-in-hand with farm animals and were exposed to all sorts of intestinal pests and germs. Our bodies developed to fight off these things. Only now we don’t have all sorts of exotic pests to deal with so our bodies are getting confused and fighting off things like peanuts and soy instead.
http://www.time.com/time/health/article/0,8599,1562607,00.html
Alexis recently posted..A Pediatrician Weighs in on Infant Reflux
Very interesting – makes sense!
Kid Id recently posted..My Son, the Party Planner
Time will tell. I’m convinced that eventually they’ll trace all these medical problems back to something seemingly innocuous that everybody uses. Like toilet paper. And when our kids are parents, living in their toilet-paper free house, they’ll tease us about what bad parents we were for letting them use toilet paper.
Alexis recently posted..What You Need to Know About Sleeping Through the Night Part 3
Ha! Yes, my baby is always perfect for the 30 minutes that we are in the office!
Thanks, Dr. Hale, for writing this article… I very much appreciate the way you respect the different needs/values/experiences of each family and work to “help each parent be successful and fulfilled as a parent so their child can be successful and loved as well.”
I think they’re just stunned into silence while they’re there.
My oldest LITERALLY cried without stopping for 6 hours. SIX HORRIBLE HOURS. He stopped on the drive to Dr Hale’s office. So I’m standing there in the exam room a stressed and sweaty mess holding out my calm and quiet baby so he can figure out why he won’t stop crying.
Alexis recently posted..A Pediatrician Weighs in on Infant Reflux
No wonder my pediatrician is reluctant to diagnose my son as having reflux. His speech and physical therapists have each expressed concern that they think he is suffering from reflux, which might be impeding his speech. When I brought it up to my doctor, she dismissed it. I guess I’m concerned that if he does have reflux, and it is contributing to his speech delay (he also suffered a stroke in utero, so a speech delay is not uncommon), I want it diagnosed and treated. Seems like quite the complicating process. Thanks for sharing your expertise.
Laura recently posted..Woman drinks too much, suffers indescribable regret as children behave as if possessed
Don’t the two therapists pro-reflux opinions outvote the pediatrician’s no-reflux vote?
We just started my 2.5 YO back on prevacid because of constant complaints that his tummy hurts and refusal of food because food “makes my tummy hurt.” This makes our 4th unsuccessful attempt to wean him off. Dr. Hale (whose kind post I’m very grateful for!) was reluctant to put him back on also (note: most kids are totally done with this BS by 1). But eventually you get to the point where your only options are a) endoscopy or b) drug trial. Shockingly nobody ever chooses the option that requires anesthesia…
Alexis recently posted..What You Need to Know About Sleeping Through the Night Part 3
Hi Alexis, my 8 weeks old baby has been diagnosed with reflux. We haven’t started him on any medication – what we do now is to put him upright in a rocking chair, carry him after each feed, burp him regularly and let him sleep on his side when we put him in his cot. I have been reading that reflux babies take a longer time and effort to sleep through the night. Is that true? I have started him on a routine soon as it will be easier for Grandmom to look after him as I will be returning to workforce in 4 weeks’ time. He is currently waking up at 2 / 3am and 5 / 6am for his feeds…
Angela,
I’m concerned that you are unknowingly making some unsafe choices with your sleep environments.I’m not sure what you mean when you say you put him upright in a rocking chair (is this the same as strapping him into a baby swing?). If this DOES mean the same as strapping him into a baby swing then great! Baby swings are awesome for refluxing kids. If however you mean literally placing him in a rocking chair made for adults then it’s probably not a great idea unless you are sitting in it with him.
But Angela my real concern is that it is not OK to put a baby on it’s side in a cot. (For US readers cot=crib) Side sleep and tummy sleep have both been shown to significantly increase the risk of SIDS which tends to peak at 4 months. I know that refluxing babies are a challenge but I strongly encourage you to stop putting him to sleep on his side – even if it means he sleeps less well – and to always put him to sleep on his back no matter what.
As to your question, an 8 week old who only wakes up 2X a night to eat is doing REALLY well. In fact he’s probably doing better than most non-refluxing babies. A typical reflux 8 week old night schedule would look more like waking up every 2 hours all night long. So yes it IS true that most refluxing babies take longer to sleep through the night. But yours is doing FANTASTIC.
Also it’s unrealistic to expect an 8 week old to sleep through the night. Technically having him only wake 2X to eat is probably about as good as it could possibly be at this age. So yay for baby!
Alexis
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