“Reflux” is a hot topic among parents. This catch-all term used to describe a baby spitting up is not necessarily a pathology or disease. As I started researching this large topic, I felt incredibly overwhelmed by how much information and misinformation actually exists with searches on social media and Google. As a result, I put on my clinician/research/nerd brain (thanks to my doctoral studies at Wash U), and started brainstorming clinical questions. What information is actually out there? What are people basing this information on? How does this information impact my patients? How can I share my evidence-based knowledge?

Now, because “reflux”, also known as GER (Gastroesophogeal Reflux), is so common among infants, there is a large pool of people online sharing their own ideas, experiences, and treatments. While I do value one person’s experience, and recognize that those experiences may correlate, the purpose of my blog and Boost Babies is to share evidence-based information. Science is founded in research. Check out this article if you want more information on evidence-based practice. With that said, I’m going to take a scientific swing at this popular topic of “reflux” and hopefully shed some light on some non-pharmacological interventions that may impact your child.

First, let’s get our definitions straight.

GER (Gastroesophogeal Reflux)- is when the stomach contents flows back into the esophagus(tube connecting stomach to mouth) with or without vomiting. This is considered normal and occurs several times a day in more that 2/3 of healthy infants. These symptoms are also painless and do not effect growth (1,2).
GERD (Gastroesophogeal Reflux Disease) - is when reflux becomes an actual pathology. The Pediatric Gastroesphogeal Reflux Clinical Practice Guidelines define GERD as “troublesome symptoms that affect daily functioning and/or complications (2).” These symptoms are more serious and long lasting and may involve acid damaging the esophageal lining (3).

50% of infants spit up many times in first 3 months. 2/3 of all 4 month olds show signs and symptoms consistent with GERD (1, 3). Again, that does not mean these symptomatic babies have the actual disease diagnosis or GERD, I just want to emphasize that it is common for infants to spit up and even experience pathological symptoms during the first few months of life. It is also worth mentioning that GI specialists still do not have a “gold standard” diagnostic tool for this disease, adding difficulty to accurate and early diagnosis in infants (2).

As a pediatric physical therapist, I have attended post-doctoral education courses on GER/GERD, poured over pages of research studies, and used my expertise in movement and positioning to highlight what I believe are key pieces of evidence-based information regarding reflux and non-pharmacological intervention.

Key Information Regarding Reflux

1) Feeding volume and frequency impacts reflux among infants.

The more time that passes after a feed, the higher the stomach acidity levels which is what damages the esophagus. When infants feed in smaller and more frequently feeds, they decrease stomach content acidity with spitting up and may decrease reflux occurrence. (Please consult your pediatrician regarding changes to feeding schedules/volumes) (1,2)

2) Positioning and stomach orientation may play a role in reflux management*

*Before I discuss this, please remember that these recommendations are NOT for a sleeping infant. The AAP recommends “back to sleep” as the safest position to prevent SIDS and safety is our priority (4).

Supported sitting positions increase reflux more than other positions.

Based on anatomy, the esophagus enters the stomach on the back (posterior) side. Supported sitting places more liquid near the gastro-esophageal junction (where the tube of the esophagus enters the stomach) increasing the incidence of reflux (5).
Poor postural control in infants younger than 6 months contributes to a “slumped” posture in supported sitting. This posture submerges the gastro-esophageal junction further with stomach contents and increases abdominal pressure contributing to reflux (5).
Overuse of seating positions like swings, bouncers, and car seats exacerbates reflux and limits infant exposure to movements delaying optimal gross motor development (5,6)

Prone with head elevation decreases reflux

In prone, the stomach contents move towards the bottom of the stomach allowing more air to be near the junction between the esophagus and stomach decreasing reflux (2,5)

Left sidelying is better than right sidelying

Anatomically speaking, when an infant is on the left side, gas is again nearer to gastro-esophageal junction than when on the right side decreasing reflux occurrence (2, 7)
Left sidelying almost doubles digestion time compared to right sidelying which lowers acidity in the stomach decreasing reflux incidence and vomiting (2,7)

3) Infants show the biggest decrease or least amount of reflux during sleep versus awake times.

Stress hormones, (cortisol) are low during sleep. Thus, good sleep helps decrease reflux. Soothing your baby with swaddling, a pacifier, or positive touch like infant massage may be effective in decreasing cortisol and improving infant sleep. Note: There is no strong clinical evidence supporting infant massage as a treatment for GERD; however, I like the science behind linking massage to better sleep and lower stress hormones (7,8).

4) Congenital Muscular Torticollis and GERD are linked.

While this study discourages making causation ties between the 2 diseases, the researchers emphasize the that relationship between CMT and GERD are statistically significant (8).
Clinicians, pay attention to those histories and systems check lists when you are working with this population.

Here is my take home message:

Check your sources. So many people have experience with reflux; however, their advice is not always based in science and might not be the best course of treatment for your child.
Promote safe sleep - the AAP emphasizes that elevating the infant’s head during supine sleep is NOT recommended and prioritizes safety due to the possibility of the infant rolling and compromising respiration (4,8).
Extensive use of seating positions like swings, bouncers, and car seats exacerbates reflux and even limits infant exposure to various movements to achieve optimal gross motor development (5,6).
Positions like prone with head elevation and left-sidelying may decrease reflux occurrence during awake times (5,7). (Do not attempt during sleep per AAP guidelines)
Increasing feeding frequency and decreasing feeding volume reduces reflux occurrence. Consult with your pediatrician prior to attempting any feeding changes (1,2).
There is a correlation between infants with GERD and Torticollis. This is NOT causation, but as clinicians, we need to be aware of the significance of this relationship during our treatments(9).

Concerned with your child’s movement or developmental health? Contact Boost Babies today!

This article is not intended to be used as medical advise. I am not a pediatrician, but a pediatric physical therapist who uses this platform to share evidence-based information with the public. Please talk your pediatrician if concerned about spitting up weight-gain, feeding, pain and inconsolable crying or other symptoms affecting your child’s health and wellness.

References:

1. Lightdale JR, Gremse DA; Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013;131(5):e1684-e1695.

2. Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018;66(3):516-554.

3. Collins J. Global. Epidemiology of Multiple Birth. Reprod Biomed Online 2007; 15 (suppl 3): 45–52.

4. Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011 Nov; 128(5):1030-9.

5. Orenstein SR, Whitington PF, Orenstein DM. The infant seat as treatment for gastroesphageal reflux. N Engl J Med. 1983;309:760–763.

6. Abbott AL, Bartlett DJ. Infant motor development and equipment use in the home. Child Care Health Dev. 2001;27(3):295–306

7. Loots C, Kritas S, van Wijk M, McCall L, Peeters L, Lewindon P, Bijlmer R, Haslam R, Tobin J, Benninga M, Davidson G, Omari T. Body positioning and medical therapy for infantile gastroesophageal reflux symptoms. J Pediatr Gastroenterol Nutr. 2014 Aug; 59(2):237-43

8.Underdown A, Barlow J, Chung V, Stewart-Brown S. Massage intervention for promoting mental and physical health in infants aged under six months. Cochrane Database Systematic Review. 2006;18(4):CD005038.

9. Bercik, Deborah PT; Diemer, Susan PT, PCS; Westrick, Stephanie PT, DPT; Worley, Sarah MS; Suder, Ryan OTR/L, BCP, PhD. Relationship Between Torticollis and Gastroesophageal Reflux Disorder in Infants, Pediatric Physical Therapy: April 2019 - Volume 31 - Issue 2 - p 142-14

Taking a Swing at "Reflux": Evidence-based Information From a Pediatric PT