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Reflux & Baby Sleep

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Cara Dumaplin

RN, BSN, Certified Pediatric Sleep Consultant

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When parents are trying to help their baby sleep, reflux can be a topic of concern.

Why? Because when parents see their babies struggle with sleep, they often wonder if a physical issue like reflux could be causing rough nights.

Even though I have twenty years of experience as a nurse, please know that this blog in no way represents medical advice. My goal is to give you a brief understanding of reflux and some practical tips related to baby sleep because we do get so many questions regarding reflux. Please talk with your doctor about this and all medical concerns.

What is reflux?anchor

In short, reflux means that the stomach contents are being pushed into the esophagus. For most babies, this is not associated with pain; for some, there is pain involved.

If you’re concerned about how often or how much “spit-up” or refluxed milk you’re seeing, make sure to check out this video.

Here’s a bit deeper explanation:anchor

Our stomachs are full of the food we eat and digestive acids. A little muscle at the top of the stomach holds everything in place. However, if that muscle is weak or not working properly, the contents from the stomach are pushed up into the esophagus. For most babies, there is no reason for concern. These babies are sometimes referred to as “Happy Spitters.”

However, for some babies the acid from the stomach can cause pain in the esophagus. These babies need to be seen by a doctor for the appropriate diagnosis and support.

Some things you might see if your baby is suffering from painful reflux:anchor

  • spitting up and vomiting associated with pain

  • difficulty being soothed/constant crying

  • becoming fussy following feedings

  • arching away from the nipple during feedings

  • frequent coughing or congestion in the absence of illness

  • wheezing or trouble breathing

  • irritability during feedings

  • refusal to eat

  • poor weight gain

  • difficult and disrupted sleep

I took my baby to see our doctor about reflux. Why does it feel like she isn’t concerned?anchor

It’s estimated that over half of all babies spit up and show signs of reflux.

Remember, some reflux-type symptoms can be normal. Reflux is caused by an immature muscle that holds contents in the stomach. All babies are born with this immature muscle. Eventually, that muscle will get stronger and will only open when a baby swallows. It will remain tightly closed at other times, keeping everything in the stomach where it belongs.

In my opinion, many doctors see parents as overly eager for a reflux diagnosis, treatment, and medication if a baby is a bit cranky, spits up at all, or struggles with sleep in the slightest.

Not all babies who show reflux symptoms need treatment. However, if you feel like you see pain and your concerns are not being heard, please consider a second opinion; reach out to another doctor or a pediatric gastroenterologist to explore your concerns further.

When do doctors get concerned?anchor

Doctors get concerned when babies begin to suffer with severe pain, have trouble gaining weight, show blood in their stool, refuse to eat, or begin to experience respiratory issues. It’s so important for everyone to work together (parents and physicians) to determine if reflux pain is truly impacting the baby.

If your doctor determines that your baby is suffering from reflux pain (referred to as GERD), you may hear some of the recommendations below.

What are ways to help and why?anchor

1) Feed baby in an upright position. Keep the baby’s head higher than the stomach.

Why? Gravity can assist milk down the esophagus.

2) Hold baby upright for 20-30 minutes after each feeding.

Why? Gravity can help keep milk down in the stomach until it begins to digest.

3) Talk to your doctor about a good probiotic. (Example: Gerber Soothe).

Why? The study, published in JAMA Pediatrics, found that administering five drops of the probiotic lactobacillus reuteri results in much shorter crying episodes, less spitting up, and less constipation.

4) Burp after every 2-3 ounces or when you switch breasts.

Why? Burping decreases the chance for an air bubble to cause spitting up.

5) Offer a pacifier.

Why? Sucking can ease the pain by increasing saliva and downward contractions of the esophagus.

Should I start an elimination diet if nursing or change baby’s formula?anchor

This can help, but please discuss any dietary changes for you or your baby with your doctor/pediatrician first.

Cow’s milk can increase painful reflux symptoms for many babies dealing with GERD. (Check labels for casein, the milk protein.) Soy can also be a huge culprit. Again, each baby can have unique sensitivities, so please work closely with your doctor before making any big dietary changes.

What about medication?anchor

Not all babies with reflux need medication, but some may. If your baby does need treatment, you will need to work closely with your pediatrician/pediatric GI specialist to find the correct medication and dosage for your baby. If you are not seeing improvement, please keep in constant communication with the doctor. Finding the correct medication and dosage for your baby may take time.

Remember: As your baby grows, the dosage may need to be adjusted.

Should my baby sleep with his head elevated?anchor

Although many parents truly believe that elevating the head of the crib or using a Rock N Play helps with reflux, the American Academy of Pediatrics does not recommend it. In this article, the AAP reports that “elevating the head of the infant’s crib is not effective in reducing reflux. It may result in the infant sliding to the foot of the crib into a position that may compromise respiration and therefore is not recommended.”

If you are currently using a Rock 'n Play (which was recalled in April of 2019), I have tips to help you wean out.

Should my baby sleep on his back? What if he spits up? Won’t he choke?anchor

All babies should sleep on their back even babies with reflux.* This position does NOT increase the risk of choking. It is, indeed, safe.

The AAP says this: “Sleep position does not increase the risk of choking and aspiration in infants, even those with gastroesophageal reflux, because infants have airway anatomy and mechanisms that protect against aspiration.”

This video will help you understand why it IS safe for a baby (even one with reflux) to sleep on his or her back:

Photo by the National Institute of Child Health and Human Development

Notice that if the baby spits up while on her back, it drains into the esophagus which goes to the stomach instead of the lungs. As the picture demonstrates, the safer position is for a baby to lay on his back while sleeping- even with reflux.

*Once a baby can independently roll from back to belly, they have the muscle strength and neck control to lift their head and safely sleep on their tummy. (Be sure arms are out of the swaddle.)

When I hold my baby upright after feedings, he falls asleep. How can he learn to fall asleep independently?anchor

We know that a baby falling asleep independently is so helpful in learning to sleep through the night.

Here are some tips to keep a baby awake while being held upright after daytime feedings:

  • Turn your baby away from you and walk around the house, look in the mirror, or show him toys.

  • Babywear with baby in an upright position (turned outward when age appropriate).

  • Use an exersaucer or baby jumper (when age appropriate).

  • Prop your baby up on your legs with your knees elevated and talk to her.

At bedtime, offer a feeding before bath time. Many bathtubs naturally hold baby in an upright position, so it serves as a great activity to break up feeding and sleep while still maintaining the position necessary to decrease reflux concerns.

For night feedings, your little one will, most likely, fall asleep while being held upright. This is okay and to be expected.

*Please Note: Certain positions, such as in a swing or car seat, can cause pressure on the stomach and make reflux symptoms worse. Try to avoid car seats and swings for 20-30 minutes after a feeding.

Will your sleep classes and resources work for a baby with reflux?anchor

The Taking Cara Babies newborn class (for babies birth - 12 weeks) can help a baby with reflux. Even though this class can NOT take away the pain of reflux, it can hand parents tools to make progress on sleep skills and differentiate between overtiredness and true discomfort.

The newborn class may not turn a reflux baby into a perfect little sleeper, but it can still give parents the ability to read sleepy cues, soothe their fussy little one, and begin to lay a healthy sleep foundation.

For those facing the Four Month Sleep Regression, our e-book Navigating Months 3 + 4 can guide parents through this tricky developmental stage; however, babies in pain will continue to struggle with sleep.

For those who struggle to fall asleep independently, wake multiple times a night, eat often throughout the night, or suffer from inadequate naps, Taking Cara Babies has an online class for babies 5–24 months called The ABC’s of Sleep.This 14-night program has a 98% success rate in helping babies achieve 10-12 hours of consolidated night sleep AFTER reflux pain is well controlled. (Please note, the 2% that do not see success typically have some sort of medical concern including, but not limited to, untreated, painful reflux.) It is very important to treat the pain of reflux and ensure adequate caloric intake before beginning any sleep training program.

A Final Thought About Reflux:anchor

Having a baby with reflux is challenging. As parents, we do whatever it takes to make our babies comfortable, and we SHOULD. Sometimes this leaves us with sleep associations and habits that are hard to break. If you are in this boat, please know you haven’t done anything “wrong.” You are comforting your baby and meeting his/her physical needs. This is exactly the RIGHT thing to do. Here’s what we know: when babies are in pain, sleep is so difficult.

Please understand, once the pain is treated, Taking Cara Babies is here to help you conquer your rough nights and naps. Until then, work closely with your doctor and can do this, Mama.

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