Reflux, colic, and gas, oh my

As a mother, I can understand the anxiety an unsettled or crying baby can cause – before having my daughter, crying babies did not phase me much, but when she was born, I would almost burst into tears of my own any time she cried. A human baby's cry is designed to be one of the most 'annoying' noises in the natural world - it is designed to get the attention of the caregiver quickly and completely.

Add the idea that they could be in pain or discomfort and the desire to fix the issues can have us reaching for all sorts of solutions.

However, as a midwife and IBCLC, I struggle to reconcile the idea/s that babies could suffer so much from these 3 digestive issues.

This is not to say that unsettled babies are a myth or to downplay the anxiety they can cause for new parents. But I think health professionals or others sometimes ‘hand out’ these terms because they do not know what else to do. And I am very concerned that we have reduced our babies to simply a digestive system and/or we expect parents to 'just deal with it'.

I can understand the desire to have a reason for the distress, but I also see how incorrect 'diagnosis' of these issues can lead to more issues.

Reflux

The Australian Health Department says that “Reflux is generally a symptom of gastro-oesophageal reflux disorder (GORD), where some gastric contents are regurgitated into the oesophagus, causing discomfort and a burning sensation behind the sternum and/or throat.” The regurgitation of the stomach contents, due to the acid, may cause a sour taste in the mouth and coughing. Wheezing may also be present.

When adults or older children suffer from reflux or ‘heart burn’ they can tell health professionals their symptoms. However, it is harder with babies - we must observe the symptoms to work out what the problem may be and this can make it easier to misdiagnose issues.

The most common signs of true reflux are pain, coughing, and wheezing

The most common symptoms I have seen in breastfed babies where reflux has been suggested are crying when put down (usually in a cot or bassinet), back arching (especially during feeding), fussiness, and maybe small amounts of vomit, especially if put down. This last symptom is probably what solidifies the idea that it could be reflux.

However, in my experience having seen hundreds of babies for breastfeeding support in the last 5+ years, it might not be reflux at all, even if the baby is bringing up milk.

The most common issue I see with breastfeeding is the way we are holding baby at the breast.

Unlike bottle feeding, breastfeeding is not just a matter of putting the nipple into the baby’s mouth.

Often, I see mothers holding the baby’s head or restricting their head movement with the crook of their arm and trying to push the nipple into the baby’s mouth.

Note that I am not blaming mothers for not knowing – it seems many health professionals do not know this either and so do not know how to help or educate new parents on proper breastfeeding positioning.

Just like adults want/need to tilt their chins up slightly when drinking, so do babies. When we hold or restrict their head during breastfeeding, they get frustrated. The back arching or fussiness could be them saying ‘I’m not comfortable’ or ‘I can’t do what my instincts are telling me to do’.

This can be the case even if this happens after a few minutes at the breast - they could go on and feed OK initially and then the back arching starts. They may have been hungry/thirsty enough to go on however, but then they realise it is not comfortable and start to fuss and pull off to say 'hey can you help me get into a better position please'.

Think about being so thirsty you just gulp water from a glass/cup quickly - you just do it. Then you take a breath and readjust, and maybe drink more slowly if you want more.

It is important to understand that babies breastfeed, not nipplefeed. The nipple needs to point up to the roof of the baby’s mouth, not go in centered. This is why we say ‘nipple to nose’ – as the baby opens their mouth, we need to hug the baby onto the breast rather than trying to push the nipple into their mouth so that a. the chin stays titled upwards, and b. the nipple is pointed up.

Crying or back arching during feeding might be baby saying they are not comfortable in that position, not that they have reflux

The first step is to ensure you have optimal positioning at the breast. Leaning back more and moving your hands and/or baby, maybe sometimes just by millimetres, may suddenly make a world of difference.

A poor latch at the breast can also lead to a more than normal amount of spitting up if lots of air can be swallowed during feeding - the baby’s mouth should form a wet vacuum seal around the breast, which should limit the amount of air being swallowed.

Good positioning could make a lot of difference

But the main question with spitting up/vomiting is ‘is it causing the baby distress?’. Keep in mind that the unsettledness caused by true reflux/heartburn is the stomach acid burning the oesophagus on the way up. Bringing up some milk may not be an issue.

True reflux may exist but may still be a symptom of an underlying issue, such as an intolerance to certain proteins or oral motor function issues. Before reaching for over-the-counter remedies such as ‘anti-reflux’ tinctures or formulas I would highly recommend that you seek out support from an experienced IBCLC.

Colic

According to the Mayo Clinic, the symptoms of colic are ‘intense crying with an expression of pain…for 3 hours or more in a day, for 3 or more days a week, for 3 or more weeks…which usually peaks around 6 weeks and subsides around 3-4months’. The unofficial definition of colic can also be ‘unexplained periods of crying in an otherwise healthy baby’ – basically the baby is crying for no apparent reason. It is said that it usually peaks around 6 weeks of age and settles around 3 months.

Colic also means ‘cramping pain’ – ‘renal colic’ occurs with kidney stones, ‘biliary colic’ occurs with gallstones, and ‘intestinal colic’ is the cramping we feel when we have something like gastro. So, by describing our babies as having ‘colic’ we are saying they are in pain. The trick is working out where the pain is.

Increasingly, I have seen parents of very young babies – 3 weeks or less – saying that their babies have colic. According to the Mayo Clinic, this cannot be the case – since the crying needs to be occurring for 3 weeks or more, a baby younger than 3 weeks old cannot be old enough for a ‘diagnosis’ of colic.

We also need to understand that babies cry. This is their only form of communication, especially in the first few weeks of their life. They may cry for many reasons – hunger and tiredness are the 2 most common reasons. Not feeling safe is another big one. These are called 'needs' crying.

And we need to understand that our babies are extremely dependent on adults for just about everything in their life – food, safety, comfort, to provide warmth, etc.

Often, I see parents who think their babies have colic because they have been through the list of what society has told them their baby NEEDS - food, sleep, a clean nappy, but we may have forgotten about what a baby WANTS.

They want to feel safe - a baby who cries when put down most likely does NOT have colic (or reflux) – they are saying ‘hey, you put me down, I don’t feel safe here, please pick me up’. Especially if they stop crying as soon as you pick them up.

They want comfort and connection - a baby who settles as soon as you put them to the breast does NOT have colic. Even if they cry when you think they have finished a feed, if they settle by going back to the breast, they do NOT have colic.

But even some normal body functions can cause a baby to cry for a short period - eg then they do a big poo, does NOT have colic. Maybe they don't understand what that feeling is...

And if your baby is exceptionally unsettled and seems to cry more than anything else they may also NOT have colic, especially if they have been unsettled since soon after birth.

Crying does not automatically equal colic. Colic means pain - first ask where this pain might be

Now, before we proceed, I want to make it very clear that I am not saying this next part to make anyone feel guilty about how their birth went. I blame the modern maternity care system for causing some/most of these issues, not individual parents.

Do any of these apply to your pregnancy and/or birth:

• Long labour or birth (active labour of more than 12hrs or pushing for more than 2hrs)

• Very quick labour or birth

• Baby was breech for a long time towards the end of pregnancy (note it is very normal for babies to be breech up to about 32 weeks or so)

• Baby was posterior for a long period during pregnancy - that means, the back of their head was positioned against the mothers back bone.

• Baby was in 1 position for quite a few weeks towards the end of pregnancy

• Baby got ‘stuck’ during labour/birth

• Baby was born with vacuum or forceps

• Baby was born by non-elective caesarean for ‘failure to progress’

Then your baby may have ‘birth strain’, a lot like an ankle or shoulder strain in adults.

Other symptoms can include favouring one head position, not liking being held in certain positions such lifting their legs to change their nappy, or seeming to prefer one breast over the other. Note that these symptoms would be present almost from birth, or within a week or so afterwards.

So, what is the solution for this?

Bodywork – seeing a professional who understands how the body works physically (eg, muscles, joints, facia, etc). I am a huge fan of osteopathy - there are many trained in paediatric/neonatal care and they do not use harsh adjustments in their treatment.

But what about babies who seem to develop symptoms of colic after a few weeks?

First, we need to rule out issues such as protein intolerances, positioning and attachment at the breast (for the reasons above), or other issues with feeding.

Often colic is explained by saying that newborns have an immature gut - they are not used to digesting milk, so this causes pain...but breastmilk, the only food on planet Earth that is produced solely to feed a human baby, should not cause gastrointestinal upset, so if anyone suggests that it is, you need to ask why, why would this food be causing your baby pain?

Again, seeing an experienced IBCLC, may be able to help you discern where the issue actually is.

And what if baby is crying because they are communicating more than a need to you? What if they are actually telling you a story or reliving a memory? We know that older babies and toddler have 'big emotions', but when do babies start feeling emotions? Could a newborn/very young baby not feel sadness? Loneliness? Scared? Angry? Maybe even the feeling of happiness could be overwhelming to them...have you have cried because you felt so overwhelmingly happy or joyful?

Maybe they start feeling emotion around 3-6 weeks and around 3 months they have learnt how to 'deal' with these emotions more. They are smiling, and their caregivers smile back at them. They have had 3 months of parents responding to their needs - they start to know they are safe and cared for.

Recently I have started talking to the babies I am seeing - not telling them to 'oh stop crying' or 'don't be silly it's not that bad', but actually acknowledging what they may be feeling - 'I hear that you are angry/upset about something, I would really like to help you' and a few times I have notice the baby calm slightly - they might not stop crying completely, but they may slow their crying or not be as loud.

In Western Society we are very quick to tell parents what their baby may physically need - food, sleep, warmth, colic preparations, etc. But what if we also encouraged parents to talk to their babies - not just 'I love you', but acknowledge that they are a small human being, with real emotions.

I would also like to add that I have worked in Neonatal ICU since 2007 - I have never seen colic listed an issue in their chart! Even babies born with severe gut issues are never diagnosed as having 'colic'...

Gas

Over the last 5+years we seem to have become more obsessed with our babies having gas and the need to burp babies.

I have worked in NICU for over 17 years, and I would say I’m pretty good at burping a baby. But the one thing I would NEVER do is wake a sleeping baby to burp them! And as a NICU nurse, I have pulled huge amounts of air out from nasogastric tubes in very settled, even sleeping, babies - gas by itself probably does not cause any discomfort.

If burping was so necessary, I am pretty sure it would become part of the medical orders - 'burp baby after every feed for a minimum of 5 minutes', but this does not exist in any medical guidelines ;).

Often, I have parents ask how to burp their baby to prevent them from having ‘trapped gas’ later. When I ask them to describe a common situation that to them describes 'trapped gas', they say something like this – the baby feeds, they fall asleep, we put them up on our shoulder, but they do not burp, so we put them down in their cot. XX mins later (anywhere between 20mins and 2hrs) they wake up crying. We pick them up, they burp, and stop crying. So, they must have had ‘gas’ because we didn’t burp them properly after feeding.

What if I told you the 2 are not related?

What if I told you that baby probably woke up because they had been put down and were ‘asking’ where you were and telling you they did not feel safe, or that they are hungry again, not because they were in discomfort from gas?

What if I told you that they probably swallowed the air while they were crying, and the burp and settling occurred simultaneously because you picked them up, not because you didn’t burp them after their last feed?

Burping is biologically normal - it is caused by swallowing air and we release that air or otherwise our stomachs would continue to fill up until they burst.

Air is lighter than water, so it rises to the top. Putting a baby vertically will most likely allow any extra air to come up through the fluid in the stomach. If baby does not burp after feeding, it is likely they do not need to at that moment, not because it is 'trapped' (if anyone says to you that your baby has trapped gas, please can you ask them where it is trapped - I would like to know the answer, as I do not know of any trapdoors in the GI system). If they burp after a period of crying, they most likely swallowed that air WHILST crying, they are not crying because they needed to burp.

A small study has shown that actively burping a baby (ie sitting them on your lap and patting their back) increases vomiting and discomfort.

If baby is unsettled sometime after feeding, it is likely not a need to burp, but rather they either want to feed again or need something else from their caregiver. Remember babies can feed an average of 11 times in 24hrs (range of 6-20 times) and sucking is used to indicate more than just hunger.

*There is also debate amongst professionals over whether babies do actually swallow air during feeding. At a conference I went to in October 2023, I heard it said that babies swallow air when they are 'gulping', not when they are 'sipping' milk - and gulping most often occurs with bottle feeding.

Burps also do not become farts. Wind from the intestine is caused by bacteria fermenting certain nutrients in the intestine. If baby seems to have a real issue with the intestinal wind (ie it is causing discomfort and/or is very offensive) then it could be something in their diet (ie via breastmilk or formula) that their body does not like. But also keep in mind that babies, just like older children and adults, fart.

Conclusion

It can be distressing for parents to hear their baby cry. And it can be hard for parents to work out why their baby is crying. Short periods of crying may be completely normal, even if they happen every day. A baby who seems unreasonably unsettled every day, especially from soon after birth, may have an issue, but this issue may not necessarily be digestive-related.

A baby may have more than just needs - they may also have wants and feel emotions, just like an older baby, child, or adult. Crying is the only way a very young baby can communicate. We may have to think beyond just their needs, to understand what they are communicating to us.

Finding the real reason for their baby's distress could help decrease a parent's anxiety and increase their confidence in caring for their baby. Finding a health professional who can look at the whole situation may help as well.

I want to help you, so if you are in Perth or Australia* feel free to reach out for a full feeding and baby assessment - www.cherishedparenting.com.au/lactation-consultant-perth

*Those outside Perth can do video consults