Reflux or no Reflux?

A mother of a 4 months old, (7.2 kg) 15 lbs 13 oz, baby writes:

“My baby boy is on reflux meds since around 7 weeks of age.  This was done because he spits up a lot and chokes while lying down.  He takes only one breast at a feeding. He won’t breastfeed unless I feed him side lying. He has always been very gassy and I think his latch is not good.  His lips do not really flange. He often will cry and fuss at the breast if we’re not side lying. He sometimes chokes on my letdown when not side lying. The fussing started around a month ago, and he has been gassy from the first week or two. I have sore nipples though not all the time. I am exclusively breastfeeding.  His weight gain has been good and the pediatrician is happy.

“I am on the mini pill for birth control from 6 weeks after birth.  The baby is taking ranitidine (Zantac) for reflux, but things are not getting better.”

So, what is going on here?  Why is the baby fussy?  Why is the baby “choking” at the breast? And why is it thought that the baby has “reflux”?

Let us consider three possible explanations of this situation:

1. This is overactive letdown reflex and the mother is producing too much milk.
2. The baby has reflux and all his symptoms are caused by reflux.
3. The mother’s milk supply has decreased in the past few months.

Which do you think is correct?

Here is an analysis of the three possibilities:

1. Baby not able to handle the flow of milk (“overactive letdown reflex”, baby “choking” at the breast, “too much milk”)

If the baby cannot handle the flow, it’s not usually because the flow is too rapid, it’s usually because the baby’s latch could be better. Mothers are frequently told the latch is perfect, but we at our breastfeeding clinic teach the latching on differently from most others and we show mothers how to achieve an asymmetric latch.

And why is the baby not latched on well?  Because of:

• The way the baby is positioned and latched on is extremely important to how well a baby gets milk from the breast. The latch determines whether a baby can handle the flow and not choke.

• The use of artificial nipples such as bottles, pacifiers and nipple shields.
• The baby has a tongue tie.  Some tongue ties are obvious, but many tongue ties are more subtle and require an evaluation that goes farther than just looking, but includes feeling under the baby’s tongue as well and knowing what to feel for.  Unfortunately, few health professionals, including lactation consultants, know how to evaluate whether or not the baby has a tongue tie.
• Those who claim that these situations happen because of “overactive let-down reflex” and “overproduction” ignore the fact that this baby was breastfeeding for the first 7 weeks of his life and was able to handle the flow. The “let-down reflex” wasn’t a problem for the first 7 weeks so why would it be a problem later when the baby is bigger? Observation of the baby at the breast shows that they may drink happily the first few minutes at the breast when they are getting plenty of milk and start to “choke” and “pull away” when they are only nibbling rather than drinking. The fact is that often “choking” from “too much milk” or “the baby not being able to handle the flow, choking at the breast” is actually a problem of the baby pulling and crying at the breast because he wants more flow.  Late onset decreased milk supply is common. And when the milk flow slows, the baby tends to slip down on the nipple and the latch is even worse, so that decreased milk supply itself can lead to more decrease.  And this may also result in sore nipples.

Therefore possibility 1 is not the correct answer.  

2. The baby has reflux.

I really doubt that exclusively breastfed babies have reflux except rarely. They may spit up but late onset spitting up as described above is a symptom of something else as explained below.  Many say that tongue tie can cause spitting up.  I have not seen any proof of this, but many of the babies with tongue tie do indeed seem to spit up a fair bit.

The diagnosis of “reflux” has become so common that one gets the impression that half the babies in affluent countries are on anti-reflux medication or anti-reflux formula.  And though on occasion, babies seem to improve on anti-reflux medication, they are the exceptions and most do not improve, as in the mother’s story above. The fact that the baby has been on medication for several months now and the symptoms have worsened instead of improving, in most other clinical situations would have made the mother and physician at least doubt the diagnosis. And the reason the symptoms do not improve is that the baby does not have “reflux” if we mean “gastroesophageal reflux disease” (GERD) which is also rare in exclusively breastfed babies. This baby also does not have another popular diagnosis – “silent reflux”, whatever that is supposed to be.  Something like a “silent headache”, because there is no pain?

This diagnosis has come about as an explanation of “fussy babies” because it is convenient. A pill for every ill. Just prescribe medication and there is no need to deal with a fussy baby and his fussy and solution-seeking mother. Most pediatricians know little about breastfeeding and rarely do they ever watch a baby at the breast.  Even if they did, few would know how to tell if the baby is getting milk from the breast.  So, a fussy baby who is gaining weight well, is perceived to have reflux.

However, again, observation of these babies at the breast shows that they are not getting milk very well from the breast and often drinking only some of the time, and pulling when the flow of milk is slow.  This doesn’t necessarily mean that he baby is not getting enough milk. In fact, this problem is the problem of the mother who started out with an abundant milk supply, so decreased milk supply could still mean a lot of milk but less in relation to what the baby was used to.  But babies respond to milk flow and if it slows, then they can slip down on the nipple and cause pain and damage of the nipple, pull at the breast further increasing pain and damage, cry at the breast, even refuse the breast altogether.  The issue is not the amount of milk the baby is getting, but rather, the way the baby perceives the flow of milk relative to what it used to be.

Clearly, reflux, possibility 2, is not the answer.

3. The milk supply of the mother has decreased in the past few months.

Spitting up (“reflux”), choking, the baby’s latch not being good, fussiness, sore nipples, feeding just one breast at a feeding and the need to feed only when side lying are all part of the picture of late onset decreased milk supply.

Late onset decreased milk supply is common in mothers who contact our clinic and may occur fairly soon after birth, even within a couple of weeks.  Why would milk supply decrease?  This mother undoubtedly has three reasons for a decrease in milk supply:

• The mother has sore nipples. Sore nipples are due almost always to a baby having a less than adequate latch.  When the baby’s latch is less than adequate, the mother may have sore nipples, or the baby may not get milk well from the breast or both problems at the same time are possible.
• The mother is feeding the baby on just one breast at a feeding which decreases milk supply.  This is not a good idea.  The mother should “finish” one breast and then offer the other.  If the baby is full, the baby will not take the second side.  But if the baby is on the first side until he is fast asleep, he may not wake up and accept the second side.
• The mother has gone on the birth control pill. I don’t know where the idea arose that the progesterone only pill does not cause a decrease in the milk supply. Our experience and that of many mothers shows that it does.  How doctors do not seem to know this can only be explained because they never make the connection and when things are not going well with the breastfeeding will simply suggest formula supplementation and then everything is fine, except that it’s not.

So the real answer for this question is 3., the mother’s milk supply and flow to the baby has decreased.

Having difficulties with breastfeeding?  Make an appointment at our clinic.

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2020