Let me tell you a little something about infant reflux: it blows chunks.
My second child, Fearlette, had severe GERD and delayed gastric emptying. It was so awful that my husband used to go around singing “Buh-lemic baby/she’s a buh-lemic baby/startin’ em young, here in sunny C.A....yeah, he’s inappropriate, but I love him).
For awhile, we thought it was “normal”. Most babies have some form of mild reflux, and spit up quite a bit. This is because the lower esophageal sphincter, or LES (a little ring of muscles which opens and closes, allowing food in – and in the case of reflux, back out – of the stomach) is immature, and weak, like most of my ex-boyfriends. In some babies, the LES is really underdeveloped, or doesn’t mature fast enough. That’s still within the realm of normal (i.e., just a laundry problem). What isn’t normal is if your baby is visibly uncomfortable – gulping or choking during or after feedings, crying before/after burps, refusing to eat – or is not gaining adequate weight. Also, amounts matter: take a tablespoon of formula and spill it on your counter. Does this look like what is spewing out of your kid’s mouth every hour? That’s considered “normal” (seriously…whoever decided this was “normal” needs to come shampoo my carpets…). If your baby is throwing up a lot more than that per feeding, or if the spit-up is “projectile” (i.e., shooting across the room), then this also may suggest a problem which requires treatment.
If you have a “happy spitter”, and that happy spitter is gaining weight sufficiently, you kind of just have to wait it out. Usually, things get better for kids like that once they start eating solids. (I’d suggest signing up for as many formula coupon resources as possible, because otherwise every time your kid spits up you’re going to see dollar signs. I think watching my daughter vomit entire bottles worth of 30 bucks a can hypoallergenic formula caused me more pain than her reflux ever did to her.) You’ll probably drive yourself nuts switching formulas, when chances are that nothing will help. However, I also am a strong believer in mommy-gut, and if you feel in your heart that your baby’s propensity for geyser-like streams of warm formula could be better handled, then seek help. There are a lot of myths surrounding infant reflux (and infant feeding in general), and if your baby doesn’t seem well, it’s important not to fall victim to those myths.
Pretty much every internet resource for reflux will start off by saying you should be breastfeeding. Breastfed kids apparently get less reflux, which is weird, considering how many posts about reflux I see on Kellymom and Mothering.com from breastfeeding moms… but whatever. Anecdotal evidence aside, it’s the accepted first line of defense against reflux. So who cares about formula? No matter which kind you use, it’s a lost cause. You already screwed it all up, lady.
In all seriousness…true reflux is a physiological issue, and while breastfeeding may prevent the harmless spit up caused by improper bottle technique (things like overfeeding, nipples with too fast a flow, etc.), the fact is that liquid is liquid. If the LES is underdeveloped, it will allow food to come back up – and it won’t really matter if that food is breastmilk or formula. Now, some studies have shown that the severity of the reflux episodes are lessened in breastfed babies – this one even posits a pretty plausible theory that this is due to breastmilk digesting more quickly than formula (as a side note, though, another study states that extensively hydrolyzed whey protein formulas provide similar benefits in that they lead to quicker gastric emptying, which is related to reflux). Regardless, though, the fact remains that breastfed babies get reflux too – and your formula feeding did not “cause” your child to have an under-developed sphincter.
Now that we’ve gotten you over that little guilt roadblock, let’s talk about which formula and bottle to use.
That was a joke.
There is no one-size-fits-all magic bottle and type of formula for reflux. Sure, there are formulas marketed for reflux – these are just normal, milk-based formulas with rice starch added as a thickener. You can also just add your own thickener (on your pediatrician’s recommendation, of course); this allows you to adjust the thickness of the formula and also use a thickener which works for you. You don’t have to use white rice, necessarily – some people use oatmeal, whole grain cereal, Simply Thick, etc. But again, PLEASE ask your doctor first. Adding cereal to a bottle is not a good idea unless it’s done in a controlled way (and if you have a premature infant, it can be incredibly dangerous if not done under the auspices of a physician). Why? Because while thickened feeds have been proven helpful, they can actually make reflux worse. As this article courtesy of Gaining & Growing states,
…(R)espiratory symptoms associated with GER may be worsened by the addition of cereal to infant bottles. Orenstein et al. (1992) found increased cough in infants with respiratory disease who were given thickened feedings. The addition of cereal to formula feedings may decrease gastric emptying time and actually increase episodes of reflux and aspiration.
And, according to this report from Pediatric Nursing:
Rice cereal used as a thickener increases the caloric density of formula and may cause constipation. Thickened formulas also require enlarged nipple holes to feed, potentially resulting in greater ingestion of air or formula, which can favor regurgitation. Because rice cereal- thickened feedings have 150% of the caloric density of un-thickened feedings, only 65% of the volume needs to be fed per meal; thereby decreasing gastric volume (Orenstein, 2001).
Adding thickener to formula also necessitates finding a nipple which allows the thickened feed to come through without your poor kid having to suck with all his might, or choke because it’s coming through too quickly. This is much harder than it seems, because while most bottle companies offer a cross-cut or y-cut nipple for thickened feeds, some work better than others. The bottles we’d invested in for Fearlette didn’t make a nipple for thicker liquids, and after mutilating- erm, I mean modifying – a slew of normal nipples after reading online that you can “just widen the hole yourself, we broke down and bought a whole new system. For what it’s worth, we found that the Avent variable-flow nipples worked perfectly – these are actually “slit-cut” (sounds creepy, but whatever), and even the thickest feeds seem to come through just fine. There is a good discussions of this topic here.
Another thing to consider is that reflux might be related to a food intolerance or allergy. Nearly half of all infants with GERD detailed in a 2002 review article had a milk protein intolerance – and in fact, the milk intolerance was provoking the reflux in some of those cases. This was true in both breastfed and formula fed babies. This is where it gets complicated, because if reflux is being exacerbated by other GI issues, it may help to move to a specialty formula. I always recommend a 24-48 hour hypoallergenic “challenge” rather than engaging in invasive testing right off the bat for any suspicion of formula-related GI issues. The way you do this is to buy one or two bottles of a quart-sized ready-to-feed hypoallergenic at the drugstore or grocery store (there are only two on the market in the US – Similac Alimentum and Enfamil Nutramigen), and try them for 1-2 days. Do not give your baby anything but this special formula, otherwise it complicates the “test”. If you see a marked improvement, you have your answer. At this point, if you want to engage in further medical testing to get a definitive diagnosis, you can go ahead and do so…. just be warned that it’s REALLY hard to get a definitive diagnosis of a milk allergy in an infant, unless your kid is one of the rare ones who will test positive on a skin-prick test. Milk allergies are weird, and some experts aren’t even sure if they involve the same reactions as other allergies or are their own separate animal. Not to mention that a severe milk intolerance will often exhibit the same types of symptoms, even though it isn’t a true allergy. See? Told you it was confusing.
As for bottles… during my time perusing the internet, I discovered that Dr. Brown’s and Born Free are the winners in reflux circles. They certainly are great bottles (albeit horrible to clean) and are designed to keep your baby from swallowing too much air, gulping too fast, and so forth. I really do feel that bottles are like relationships – what works for you may not work for me. I go for funny, sarcastic and artistic men, you might like confident, athletic, professional men/women. We all have our preferences. Same with bottles. I have yet to find a study that looks at the relationship between brand or type of bottle and reflux, so I can’t really give much advice on this. I’m honestly not sure it matters – again, if we’re talking true reflux here, as long as that liquid is going in, it’s gonna come out.
However, there are some mechanical things that make a difference. Feeding your baby at a slight angle – NOT sitting up at a 90 degree angle, as that can make things worse; keeping her upright after a feeding so that the gravity will help keep the liquid down (slings and infant carriers come in handy for this); burping at regular intervals (we would do it after every ounce or two in the beginning, when things were really bad… it never did seem to help, but every medical resource says to do this, so I felt I should mention it). Basically, all just basic good bottle feeding techniques, except for having to keep your baby upright and immobile after feedings. That part sucks. Young babies often fall asleep during feedings, and older babies want to play. Both scenarios pose challenges. That’s why the sling works so well – for younger babies, they can sleep while held at least kind of upright; for older babies, you can keep them upright and somewhat immobile yet still engaged.
I know it all sounds confusing, and it is. As I said before, infant reflux really blows. But the good news is, almost all babies grow out of infant GERD before their first birthday. Although it will probably take a bit of trial and error, I promise you – with the help of a good pediatric GI and some experimentation, you will be able to make your own Bulemic Baby much more comfortable.