Thursday, 28 May 2015

Reflux and breastfeeding

Reflux - it's a biggie.  There's a good chance that in the early weeks of your baby's life you will wonder if he has reflux, or have it suggested to you.  You likely know other babies who are on medication for reflux.  It almost seems that reflux is queried now for any fussy feeding or unsettled behaviour, but is anyone actually looking at why that baby is unsettled?  Reflux exists of course, but is it a medical problem, and do all these babies need medicated?  I believe that many cases of reflux are actually indicating a feeding issue, and have non medical solutions. This blog will concentrate on breastfeeding and reflux, but in fact the principles are applicable to any bottle feeding too.
Reflux is common and physiologically normal.  The NICE guidance describes it as follows, 

"Gastro-oesophageal reflux (GOR) is a normal physiological process 
that usually happens after eating in healthy infants, children, young people and adults...
GOR is more common in infants than in older children and young people,
and it is noticeable by the effortless regurgitation of feeds in young babies."

Babies are different from adults.  When an adult vomits it's generally a sign that something is wrong, and with no one talking about the normalcy of reflux in babies, mums feel something is wrong with their baby.   The NICE guidance suggests that 40% of babies spit up/vomit, and for the vast majority of babies it is a laundry issue, not a medical one.  
Some babies are diagnosed with  'silent reflux' where milk begins to reflux back towards the mouth and either doesn't make it as far as the mouth, or is reswallowed once it gets there.  Sometimes a mum hears swallowing or sees other symptoms like baby hiccuping and perhaps eyes reddening.  Sometimes there are no visible symptoms of milk movement at all and reflux is diagnosed simply from crying, back arching, pulling on and off the breast ( which is sometimes misdiagnosed as breast refusal).

A common picture is that a mum with a concern visits her GP.  After a discussion around symptoms baby is often started on a milk thickener, and so starts the medication cycle.  It is difficult to administer to a breastfed baby as adding it to breastmilk digests the thickener.  This makes you wonder about the efficacy in the stomach!  Thickeners make many babies constipated and the now constipated baby has tummy pain and is more unsettled and fussy.  This often becomes confused with more reflux symptoms and so the baby is moved on to the next level of medication - proton pump inhibitors which reduce stomach acid.

Can we all just take a step back? Imagine your washing machine is leaking.  Each time you wash a load of clothes you see a puddle of water gathering on the floor.  You call a plumber and explain about the puddle of water.  Your plumber diagnoses a leak and suggests you change a valve to reduce the amount of water which fills the machine.  Now when you use the machine the puddle is smaller but your clothes don't seem to be washed properly either.  Is that an acceptable solution? 
You call a second plumber.  This time the plumber comes to your home and observes a wash.  He pulls the machine away from the wall so that he can observe the entire water cycle and notices that one of the pipes is loose.  He fixes it.  No more puddle. Your clothes get washed, the floor stays dry and everything works as it should because he understood what was causing the problem and removed it, rather than working on the symptoms.

Why are we not looking for the root cause of a baby's reflux?  Why are we managing symptoms?  Deal with the root cause and maybe we can eliminate the problem with reflux.

So what are the root causes?
1.  It's a baby -  The spitting up may be entirely normal.  Babies have little core strength and many spend a lot of time either semi horizontal or horizontal.  They have a liquid diet and can have an immature valve closing the top of the stomach, so that makes it leaky.  It's a bit like half screwing on the top of a bottle of water and then laying it down.  The water is going to leak back out of the top.  This normal physiological reflux generally resolves in time as the baby begins to sit up and moves to solid food.  In the mean time it may actually be beneficial.  The Canadian paediatrician Jack Newman believes that spit up may be a good thing in an otherwise healthy, content baby as it coats the oesophagus twice with antibodies - once on the way down and once on the way up again. The NICE guidance is very clear that either spitting up or silent reflux in and  of itself is not a problem and should not be medicated without other symptoms being present.

2.  Aerophagia - This is a medial term which just means swallowing air.  This is a huge cause for many cases of reflux.  A baby who is clicking, gulping, spluttering may be taking in air.  A baby who has a sub optimal latch may be taking in air.  Scheduling feeds and feeding on a very full breast or expressing for a freezer stash can create issues with swallowing air, as can a tongue tie or a birth issue.  In my previous blog I talked in detail about why a baby may swallow air during a feed so if you missed it click here.  As the air comes back up, milk comes with it.  The resolution for this is to correct breastfeeding management, or resolve the structural issues so that air isn't swallowed.  Without the air being swallowed the reflux can be eliminated or reduced to a manageable level.  Having a good breastfeeding assessment will help to optimise feeding and identify any issues with air intake.

3.  Low Milk Intake - This is more usually applicable to silent reflux where the diagnosis has come from symptoms of back arching, pulling on and off the Breast (which may have been misdiagnosed as breast refusal), and poor weight gain.  The poor weight gain is sometimes considered to be due to "silent reflux" causing pain, however the most common cause of poor weight gain is lack of calories so this should be investigated first.  Where milk supply is low the flow of milk is slow.  It is a very common behaviour for a baby to arch, pull on and off the breast and cry in frustration when flow is slow.  Milk volume is a complex interaction  of both mum and baby so low supply could be due to ineffective transfer from mum to baby due to birth interventions, something anatomical, poor latch, or baby not being at the breast enough.  Resolution would be to increase supply in mum and ensure baby is transferring effectively.  A good breastfeeding assessment and support can help to get things back on track.

4.  Allergies/intolerances - This is a more complex picture.  Sometimes where a baby is combination fed, reflux can result from issues with formula.  Where a baby is exclusively breastfed there can be issues with mum's diet.  In our society we are very dairy and gluten based, both of which are very allergenic foods.  Some research studies have found that milk proteins can pass through Breastmilk entirely unchanged.  The reason for this isn't clear.  Perhaps it is due to mum's own gut having damage from early introduction of dairy or solids, perhaps it is due to modern processing of milk, or maybe due to genetic changes in milk.  Regardless of the reason, many mothers do find that reflux symptoms improve if they remove dairy from their diet.  Some are fine with cultured products like cheese and yoghurt but not milk, and some need to remove all dairy.  Some find this is only temporary and once older baby can tolerate the food.  Getting to the root of the intolerance and removing it from the diet improves the reflux symptoms.

5.  Gut microbiome - Our gut bacteria is a huge topic of research at the minute.  We have more bacterial cells in our bodies than human cells and a healthy microbiome is necessary for digestion and for immune function, among other things.  A recent small study in adults showed that GORD (gastro oesophageal reflux disease) was associated with pathogenic strains of bacteria in the oesophagus.  Other studies have shown an improvement in reflux symptoms with probiotic supplements. 

6.  Baby's habitat - A baby is extremely immature at birth, with a nervous system reliant on mum's body.  If a baby is not in contact with mum, digestion does not work optimally.   We have been primed to believe that we need to set a baby down after feeding, not to spoil our babies, or create rods for our backs.  When a baby is separated from mum however the baby can become distressed, and emotional stress can lead to vomiting.  This may explain why baby wearing / carrying baby also seems to help with reflux.
Usually babies are not bothered by reflux, but they do receive emotional regulation from their mum.  If mum is worried, stressed and scared by watching their baby spit up, baby becomes worried and scared due to mums reaction.  This can start a cycle of anxiety and distress with spit up.  The normal reflux can then be misdiagnosed as GORD due to the baby's distress.  A good breastfeeding assessment should involve counselling about what is normal, and concentrating on mum's concerns and fears just as much as the baby's feeding.

NICE guidance is very clear on where normal reflux becomes something which needs investigation.

"in well infants, effortless regurgitation of feeds... 
does not usually need further investigation or treatment"

For silent reflux it states the following:

"Do not routinely investigate or treat for GOR if an infant or child 
without overt regurgitation presents with only 1 of the following:  
  • unexplaied feeding difficulties (for example, refusing to feed, gagging or choking)
  • distressed behaviour
  • faltering growth
  • chronic cough
  • hoarseness
  • a single episode of pneumonia"

If a baby meets the criteria for further investigated, the guidelines are also clear about what should happen next:

" In breast-fed infants with frequent regurgitation associated with marked distress,
ensure that a person with appropriate expertise and training
carries out a breastfeeding assessment."

Is this happening?  If your baby was diagnosed with reflux were you first referred to a person with appropriate training to carry out a breastfeeding assessment?

What's wrong with the medications?
Most mums don't feel comfortable with the idea of medicating their tiny baby, and side effects of the drugs are often not discussed in depth.  Thickeners often have a side effect of thickening stools or causing constipation.  Proton Pump Inhibitors (such as Losec) or H2 blockers (such as ranitidine)  reduce stomach acid.  These do not stop the reflux (in fact vomiting is listed as a side effect).  Reducing acid may initially seem like a good idea, but we have stomach acid for a very good reason. Our bodies need an acid environment in  order to digest proteins, and it also acts as an immune defence against pathogenic bacteria which are destroyed in an acidic stomach environment.  It also suppresses appetite.  In cases where the issue is low milk intake the drug may seem to help for a while, but the supreased appetite can mean that baby takes even less milk from the breast, and mums supply lowers  further and then the issue begins again.  Itt affects absorption of vitamins and minerals in the gut and some studies have found increased risk in respiratory illness.  With these side effects, and the clear guidelines from NICE, doesn't it make sense to investigate fully before considering drugs?

There is no doubt that some babies do have GORD.  These are very unhappy babies, and they need our help.  They may indeed need medication, but they also need help with breastfeeding.  Those babies are in the minority though.  Most babies probably don't need medication, but they absolutely do need good breastfeeding support.  A thorough breastfeeding assessment should involve observing a feed, optimising latch, and looking at a complete history of feeding so far.  It should consider baby's ability to transfer milk, weight gain and pattern of feeding through the day, any extra expression that happens regularly, how birth went and if there could be subtle effects, mum's feelings around breastfeeding, pain or discomfort, concerns or fears etc.  It should considers mum and baby as a unit and is much more than treating symptoms.  A breastfeeding counsellor or lactation consultant should also know when reflux is more than a feeding issue and does need medical help.

 Reflux is distressing -  for the whole family, and our babies deserve to have someone take the time to investigate and treat the cause, not just symptoms.

"For every effect there is a root cause. 
 Find and address the root cause rather than try to fix the effect, 
as there is no end to the latter." - Celestine Chua

Further Reading

NICE Guidance on reflux and GORD

Gut Microbiome

Baby's digestion and need for Skin to Skin

Wednesday, 13 May 2015

Fast letdown/choking/clicking. Is it oversupply?

You've got through the first couple of weeks of breastfeeding and just as you start to feel it's going ok, your baby has started gagging and choking while feeding or maybe she is latching off and on and getting her face sprayed with milk.  Maybe during feeds you are hearing a clicking sound. Your baby also suddenly seems very gassy and upset.  You asked your HV who suggested it could be reflux.  A friend suggested it was a tongue tie.  You asked "Dr Google" who popped up lots of links on Fast or Forceful Letdown / Oversupply and gives a solution of Block Feeding.  This is a common scenario and a large proportion of mums and babies have this experience to some extent.  Do they really all have reflux/colic/tongue tie?  Do all these mums have oversupply?  Could it be that again, we are just not understanding the big picture?
Babies have a very complex suck-swallow-breathe coordination process requiring a large number of nerves and muscles working together.  When breastfeeding a baby's tongue has a rhythmic wave-like motion which means that the baby can nearly continuously breathe while sucking.  The basic process is as follows:  Milk is transferred from the breast into the baby's mouth.  Baby then takes a breath while moving the milk to the back of her throat in preparation for a swallow.  As the milk reaches the back of her throat area she does a short exhale and then holds her breath while she swallows.  After the swallow is complete she exhales the remainder of the held breath.  It is a very complex and intricately timed process.  When a baby is gagging /choking or spluttering at the breast it is generally because the smooth coordination of the suck-swallow-breathe rhythm has been disrupted and the swallow and breathe is mis-timed. As adults we still occasionally have mis-timed swallows, and we might talk about a drink having gone "down the wrong way".   We can put down the glass and recover, but for babies the milk continues to flow.  That leads to difficulty keeping up with flow (choking/spluttering) and also commonly leads to swallowing air which later results in gas or reflux.   Gassiness and reflux are big issues and really need a blog to themselves (coming soon).  In this blog I want to solely look at the idea of the fast letdown and whether it is actually an indicator of oversupply.

Why now?

Many mums and babies notice this happening around 3 weeks.  A big part of the reason for the timing is the change in milk supply.  Milk volume changes rapidly in the first couple of weeks.  In the first few days of colostrum a mum is producing maybe a teaspoon or 2 of milk at a feed, averaging about 30-45ml over the course of 24 hrs.  When her milk "comes in" there is a rapid change to large volumes of milk building over the first 2 weeks.  By the time a mum gets to around 14 days she may be producing 800ml of milk over the course of a day.  It is an enormous change.  With the volume the letdown is a bit faster, but a fast letdown and oversupply are entirely different things.  Fast milk at letdown is normal!  It is normal and expected that milk will begin to spray and it makes complete sense when we think about what is happening within the breasts.  Inside the breasts milk is stored in ball like structures called alveoli which are surrounded by muscle fibres.  At letdown the muscles contract and literally squeeze the milk into the ducts and down through the nipples.  A crude analogy would be to think of a bath toy which sprays of water when you squeeze it.  This is what happens at letdown and is normal.  A baby should be able to handle this ideally,  but lots of things can impact on the suck-swallow-breathe coordination.   A baby struggling with the flow does not necessarily mean that mum has a faster than normal letdown or that she has oversupply.  It can mean that mum has a completely normal letdown and normal supply but that her baby is struggling with the normal flow!  

Why would baby have problems coordinating the flow?

There can be lots of different reasons why this might happen with a normal supply.  It may simply be due to immaturity.  The suck-swallow-breathe coordination matures at different rates and completely mature coordination may only develop at 42 weeks gestation for some babies, or even in the weeks following birth for other babies.  Gestation lengths of babies varies enormously, and that means what we think of as  a 2 week old baby can vary enormously.  A baby born at 42 weeks for example may have 5 weeks further development than a baby who was born at 37 weeks, even though they are both considered full term babies.  Those weeks can have a big effect on a baby's coordination.  Given that as adults it still happens us from time to time, it shouldn't be surprising that an immature newborn would have this experience.
It could be due to the latch.  A baby who isn't well latched to the breast won't have as good coordination of milk transfer and may splutter at the breast.

It could be something that happened at birth.  A baby's skull undergoes significant moulding at birth in order to let it travel through the birth canal.  Think of the shape of a newborn's head immediately after birth and how it changes over the first few days and weeks.  Add in the impact of any medical interventions on the skull shape.  Forceps, vaccum birth or cesarean section can cause different moulding to a baby's head.  Any moulding of the bones affects the muscles which are attached to those bones - including the muscles which are used to latch, suck, swallow and breathe.  This can be a factor in coping with the letdown.  Even where structural issues aren't in play, medications can be?  Studies have found that having an epidural during labour to have an effect on suck-swallow-breathe coordination for up to a month, for example.

In some cases an anatomical issue can be the cause - something like a tongue tie, which impacts on tongue movement and ability to deal with the letdown.

Perhaps it's none of these things.  Perhaps it's just the way breastfeeding is being managed.  Maybe you are focused on feeding at certain times?  Maybe you are feeling engorged?  Maybe you are still in a little pain and are holding off feeding for a short time after you see early cues.  Any of those factors which lead to the breasts being fuller increases the pressure in the breasts and consequently the speed of the letdown.

Does this mean it is never oversupply? No - of course a baby having difficulty can be a symptom of an oversupply of milk but in that case your baby's extra weight gain is also an indicator.

Is block feeding the answer?

The basic premise of block feeding is to divide the day into blocks of time and to feed from one breast during each block thereby reducin stimulation and milk production.  It works!  It works very effectively and very quickly, and that means it needs caution.  If your baby is struggling but not gaining excessively (which is the more likely scenario) then block feeding will mean that you reduce your supply and that may impact your baby's weight gain and growth.  Many IBCLCs now urge caution with block feeding, suggesting it should only be used if a baby is gaining over 1lb a week.

See the big picture

Rather than jumping to a solution of block feeding it makes sense to look for the cause of the feeding issue.  While block feeding may help for true oversupply, where the issue is simply baby being an immature newborn block feeding may hinder rather than help.  It may stop the choking but at the cost of limiting that baby's source of nutrition.  Milk supply is being set up in the first 5 weeks so it makes sense to be cautious about reducing milk volume in that time.  

Often we need to just consider the normalcy of what is happening - an increasing volume of milk and an immature baby!  Breastfeeding is a holistic process and we need to manage it in that way.  Many times all that is needed is a change in position.  If we have difficulty keeping up the flow of water in a glass we simply lower the glass so that it flows more slowly.  The same principles apply.  Shifting your body so that your baby is lying more on top of you means that gravity slows the flow.  Sometimes that is all that is needed.  That position can often deepen the latch, which also helps.  All you need to do is lean back.  If your baby is still struggling in that position it can help to just remove the letdown from the equation altogether.  You can just unlatch when your baby begins to struggle and let the milk spray into a muslin or hand towel and then relatch when the flow slows again.  Some babies do this all by themselves as they have worked out that it's easier that way.  

Usually within a short time the gagging/choking is no longer an issue.  Maybe it's because the baby just gets more mature each day or because any birth issues have resolved.  Maybe he learns to manage the new faster volume, or maybe it's because supply and baby have just got into a better sync.  In fact it's likely that in a couple of months the same baby will be wanting to get that fast flow straight away and will let you know if he isn't!

If positioning doesn't help, or if your baby is having difficulty through all of the feed, not just letdown, look for experienced breastfeeding support.  If you feel you do have oversupply and want to check if block feeding is actually the right route for you look for good breastfeeding support like a breastfeeding counsellor or lactation consultant.  Oversupply may be the result of excessive pumping, or inflammation /infection in mum?  The right supporter for you will look at the breastfeeding picture as a whole, and as you and your baby as one unit.   See the big picture.  Our babies are still learning to feed in these early weeks and their muscles and nerves still developing.  A fast letdown isn't something that necessarily needs fixed, in fact in can be a really reassuring sign that your milk supply is building nicely. We just need to support our babies while their feeding matures.

Further Reading