What is reflux? How does it manifest? What can be done about it?

Reflux comes in two forms productive and silent. Productive is obvious because it is accompanied with lots of vomiting. Silent is less so because it isn’t. However, both are equally distressing being characterised by sudden bouts of apparent pain that often leads to inconsolable upset. Feeds are frequently fussy, short and uncomfortable. Sleep may be disturbed. Some children lose or fail to gain the appropriate level of weight. Some projectile vomit. Others cough and sneeze. What is going on? Why do some children suffer, while others do not? What can be done about it?

Before we start, I would like to draw your attention to the last three signs mentioned above. Although they may be nothing, they are all slightly more serious and as such need to flagged up to your GP. Weight loss or slow weight gain may just be your child finding their own, natural, genetically-lead weight gain profile. However, if they drop two or more percentiles, that is a fall of two or more lines on the weight graph in your little red book, it is worth investigating.

Projectile vomiting can be associated with Pyloric Stenosis. The pylorus is the part of the stomach that connects it to the small intestines. It is where the food goes out. Like the rest of the stomach, it is muscular. At the point where the food exits it forms a circular sphincter. Sometimes the pylorus doesn’t grow at the same rate as the other parts of stomach. So, in comparison, over time, it becomes small and tight. When this happens, the stomach has difficulty emptying and, instead of food passing through the pylorus into the rest of the gut, it is pushed back the way it came and with some force, hence the trajectory. If you find this happening a lot, visit to your GP.

Coughing and sneezing may be a sign that milk that has come up from the stomach is irritating the upper respiratory tract. The upper part of the oesophagus (tube leading from the mouth to the stomach) and respiratory tract sit very close to one another in the pharynx (throat). Hence food/milk coming up from the stomach can irritate the upper respiratory tract. As before, medical advice should be sought.

Having got that out of the way, let’s have a look at what is going on?

At the top of the stomach, bottom of the oesophagus, there is another sphincter or circle of muscles called the lower oesophageal sphincter, LOS. When we eat food passes from our mouths to the stomach and, hopefully, does not come back, even if we stand on our head. It is the LOS that is responsible for this. We can think of it, to some degree, as a string at the top of a bag. When the string is loose the top of the bag is open and we can put stuff in it. When the string is tight the bag is shut and nothing can get in or, more importantly, out. In reality the LOS is slightly more complex. The mechanism of opening and closing, for example, is dependent on the pressure gradient across it. When pressure is high in the oesophagus the LOS should open allowing food to pass through to the stomach. It is not supposed to work the other way round. That is when the pressure is high in the stomach the LOS is not supposed to open to allow food back the other way. However, the LOS and its neurology take time to mature. So, when we are little this mechanism may just not work very well and the milk we ingest might flow back into the lower oesophagus. If there is stomach acid in it, we will experience pain. Babies are predisposed to this because their diet is liquid, they eat lying down and, if they are breast fed, the milk ingested slows stomach emptying. Also, most babies are gassy. Gas in the stomach or lower gut puts pressure on the LOS and, being immature in its function, may force it to open.

Hiccups are another consideration. Hiccups are a spasming of the diaphragm. The oesophagus passes through the diaphragm on the way to the stomach. The LOS sits just beneath this passageway. It is attached to it by thin strands that also blend in with its muscular bulk. So, the LOS sits near, is attached to and is even made up of bits of the diaphragm. Not surprisingly then, when an infant gets the hiccups the LOS is put under stress and reflux is the possible result.

Then there is the labour. Uterine contractions are spiral in nature. They push the infant through the birth canal in a twisting, spiralling motion. These forces are absorbed by the infant’s body and tend to resolve in areas that are most mobile, namely the very top and middle joints of the back. The top joint is associated with a nerve called the vagus nerve. The vagus nerve has very many functions, one of them being the opening and closing of the LOS.  As such, disturbance at the top joint may leave residual vagal irritation that might result in reflux. The middle joint is associated with the diaphragm just where the oesophagus passes through it and just above where the LOS sits. Even a simple, straight forward birth can irritate this joint, over load the diaphragm and displace the LOS causing it to malfunction. Another area to consider is the neck. The neck is easily compromised by the birth process especially if the baby gets stuck and forceps, ventouse or syntocinon are required. The neck can also suffer if the infant has been lodged down in the pelvis for too long. This is often the case for second and third children because the pelvis is looser. The nerve to the diaphragm comes from the neck. If the neck is compromised this nerve may also be compromised. Facilitated nerves cause muscle spasm. So diaphragmatic spasms or hiccups may result and, as mentioned above, hiccups predispose reflux.

So, there are many reasons why infants might suffer reflux. Some are logistical: babies have a liquid diet, they feed lying down; breast milk slows stomach emptying; etc. Then there’s gas and hiccups, both of which compromise the LOS. Pre-birth presentation and labour also come into play. Again, certain of these interfere with LOS function. Then, of course, we must not forget immaturity. The LOS may simply be immature, unable, as yet, to do its job properly. Reflux will result. Understanding cause is important. It helps formulate management. If the problem is logistics, for example, you might find that short, frequent feeds, holding your baby upright and tilting the cot, all help. Gas, hiccups and birth-related LOS dysfunction may require a look at the mechanics. Paediatric cranial osteopaths, such as the Osteopath Clapham, are body mechanics and might be able to assist. If immaturity is the issue then unfortunately it is just a waiting game. In this case you may wish to visit your GP. There are several medications that might make life easier. They are tiered and have their own associated issues but are often a helpful interim measure. As a qualified paediatric cranial osteopath, with over ten years of experience, I am very happy to see if I can help. Please do contact me at the details given below.