Managing Silent Reflux

The information provided on Crying Over Spilt Milk is designed to support,not replace,the relationship that exists between a patient/site visitor and his/her existing physician. Please do not change medical treatment without first consulting a personal health professional.

General Management Techniques

Raise the head of baby’s bassinet/cot and changing surface to 30 degrees. Raise the whole cot/bassinet rather than putting something under the mattress. Put feet at the end of the bed or use safe-t-sleep to keep face clear of covers.

Use a front pack, sling, exersaucer, swing (as age appropriate) to keep baby upright when awake. A Hammock may be useful.

Winding/burping regularly (preferably high on the shoulder with a nice straight body to allow the wind to escape more easily).

Avoid pressure on tummy at all times.

Wrapping for sleep.

Sleep pattern in place.

Avoid “crying it out” as crying worsens gastric reflux and is distressing to family. Bad sleep behaviours do not develop and sleep patterns are easily established once gastric reflux is adequately controlled.

Pacifier/dummy like NUK brown rubber teat (this is only an option if LMC and Parents are comfortable with it). Sucking gives comfort but feeding continuously may exacerbate or encourage more GR episodes so this is where a dummy can be a helpful tool.

Mother’s diet is in moderation (i.e. dairy, gluten, acidic foods like tomato, orange etc.). See Food and Reflux.

Wind preparation like Weleda colic powder (this can help with wind if baby wakes early and is uncomfortable. 10 ml boiled water or Weleda colic powder in 10 ml of water can wash the oesophagus, bring up remaining wind and allow baby to return to sleep).

AND

BREASTFED

Dairy free diet for mum for up to two weeks*

AND

Check latching/feeding,flow of milk and position

Not working?

BOTTLE-FED

Non cow’s milk based formula for one week**

Not working?

Gaviscon Infant powder – every feed for three days

Not working?

Referral to a paediatrician – start Ranitidine

Not working?

Can dosage be increased??

Not working?

Add a motility medication
OR
Change Ranitidine to Omeprazole

Not working?

Can dosage be increased?

Omeprazole not working?

BREASTFED
Gluten free diet for mum for up to one week*

BOTTLE-FED
Next step

Not working?

Tests needed.

pH study to evaluate the presence and extent of reflux

Barium swallow to rule out anatomical abnormalities

Gluten sensitivity blood screening before considering fundoplication surgery or after 18 months of age if reflux still ongoing. See www.drrodneyford.com or the book “Are you gluten-sensitive? Your questions answered” by Dr Rodney Ford for details.

Gastroscopy – an important investigation to evaluate the presence and extent of reflux oesophagitis

Tests confirm reflux oesophagitis??
(With no evidence of gluten sensitivity and/or no response to change in diet.)

YES

Consider fundoplication surgery

Consider other possibilities for symptoms, food allergies and intolerances, delayed gastric emptying, coeliac disease, learnt behavioural patterns, side effects of medications, other motility disorders etc. etc

Testing may be appropriate at any time throughout this process. However, it is essential that before surgery is considered, all tests are repeated to evaluate the nature and extent of the reflux at that time.
More than one treatment option or test may be recommended at any one time as each child’s family history, gastric reflux symptoms or combination of symptoms may differ, and indicate the need to quicken the process of getting symptoms under control (e.g. failure to thrive) or indicate the need for a different approach (e.g. family history of coeliac disease)
If a pH study shows reflux, but a gastroscopy shows no oesophagitis, this is confirmation that although the child has reflux, it is well controlled on medication. Other reasons for continuing symptoms should be sought.

If you have a child who gets both pain from reflux and vomits/spills, you will need to refer to the charts showing treatment options for both “Silent Reflux” and the “Happy Chucker”.
However, an important point to note is that with babies who get pain from reflux as well as vomit, it is important to control the pain and acid first before considering the use of thickeners or thickened formulas. When the pain/acid is under control with appropriate acid reducing medications, then try the options on the “Happy Chucker” chart. Babies who get pain due to reflux all have some degree of oesophagitis (inflammation/ulceration of the oesophagus). Studies have shown that although thickeners and thickened formula may reduce the number of episodes they prolong the length of time of the remaining episodes as thickened fluid does not drain as well from the oesophagus. It is these prolonged reflux episodes, when they contain acid that can do the most damage.

*The time frames mentioned for these diets are the length of time that the diet should be trialed for by the breastfeeding mother before deciding that they are not helping and before returning to a normal diet. The dairy free diet and/or gluten free diet needs to be a complete removal of these foods as cheating does matter. A positive response may be seen earlier than the time frame indicated. If the baby has started solids then these also need to be free of dairy and/or gluten. If the diet is successful in resolving symptoms then it needs to be continued or another form of feeding considered. Breastfeeding is nearly always best for the baby with gastric reflux but the mother’s health is also important, so consider this decision carefully with the help of a paediatrician for future feeding options.

**There are three options for non cow’s milk based formulas.

Soy based formulas are not recommended when soy is the only source of nutrition. Therefore, a child who is bottle fed only (with no solids) would be best not to be on a soy formula.
Goat milk formula is often effective in children with reflux problems due to cow’s milk protein intolerance. (Opinions vary about the suitability of goat’s milk due to the proteins being similar to cow’s milk so this may need to be discussed with your health professional.)
Hypoallergenic formulas are best recommended by a paediatrician as a special authority number is required to receive these subsidised (otherwise they are around $100 per tin).

See our fact sheet on “Infant feeding” for more information. If the baby has started solids then these also need to be free of dairy.

NB: The evidence to date is that delayed gluten introduction (at about 12 months) reduces subsequent risk of coeliac disease. However, this risk is also reduced if gluten is started in the baby’s diet whilst still breastfeeding. It is thought that this may be because the mother’s milk contains antibodies to gliadin (component of gluten) which will prevent a sensitivity developing. (Gluten can cause gastro-oesophageal reflux disease! Author: Dr Rodney Ford).