Time to Put Infant Reflux Back In Its Box

In all walks of life there are times when you get to enjoy the liberating feeling of being told something you’ve always known to be true, but never quite had the knowledge you needed to confirm your inner convictions. This happens to GPs all the time, because we have convictions and feelings about most of the medicine we encounter on a daily basis, but too little time to research all the myriad quandaries we are left puzzling over. This is where specialists have their use – they are able to dedicate years of study to one or two of the dilemmas we are faced with, and help point us in the right direction.

So it was this week, that one such specialist empowered me with something of a eureka moment over a condition that has been troubling me recently – the increasingly medicalised language surrounding ‘sicky’ babies.

By ‘sicky’ I mean milk-spitting, vomiting, puking babies that leave permanent milky-white stains on the shoulders of all their parents’ best clothes, require investment in dozens of muslin squares and lead to the pulling up of carpets in favour of wipe-clean lino just before the baby miraculously grows out of it. Or to use a lovely, old-fashioned word that we need to keep hold of: possetting.

What I do not mean, is gastro-oesophageal reflux.

Reflux is a highly medicalised word. It is not normal; it implies acid spilling backwards from stomach to oesophagus and (as any pregnant woman knows) painful heartburn. True acid reflux can occur in babies, but it is rare; paediatric gastroenterologists at the conference I attended this week were queuing up to testify as to how unusual it is to have positive tests for acid reflux in possetting babies. This fits with the experience of having a possetting baby (and I have bought my fair share of muslin in my time) – babies are not usually distressed by pain when they posset, and the milk smells just like that – milk, and not acid.

Despite the fact that the entire feed of milk seems to find its way into the washing machine rather than the infant stomach, babies who possett thrive – they put on weight and develop without problem. They are irritable some times, but most babies have times when they are more irritable than their parents would like. If possetting is very common, and irritability is very common, then there will be many babies that experience both, but that doesn’t mean that the possett is the cause of their irritation – or, more  importantly, that treating ‘reflux’ will make any difference to one or either symptom.

Many advice websites give quite a balanced view on this issue, with sites like the BabyCentre and netmums giving lots of reassurance that it is usually normal and will settle on its own before mentioning any medical treatment for it – but they still call it reflux, because the word has entered popular use. Fascinatingly, what I also learned this week is that if parents are told their baby has reflux they are more likely to want medication for it than if the doctor gives the same explanation of the problem, but avoids using the medical label.

Medical labels matter, they create anxiety that your baby has a problem that you should be trying to solve, and can turn a normal, healthy baby into a patient before they have barely got going in life. We need to normalise this process and recapture the word possetting for the nursery and not the doctor’s surgery.

So what of the science behind treatments for ‘reflux’? Well the first thing to say is that true Gastro-Oesophageal Reflux Disease can occur, although it is rare. We need to be concerned about a baby that is failing to thrive (that is, is not growing properly and putting on weight in the normal way), or if the vomit contains blood, or is associated with significant breathing difficulties. These babies may well need to see a paediatrician.

For the vast majority of possetting babies, however, the point in question is this: will any treatments that are offered make any difference to how often my baby is sick, or to how irritable they are? The answer to these two questions is a resounding ‘no.’ Simple measures such as making sure you don’t overfeed, slowing down the feed and winding regularly are all common sense, but changing feed to an expensive ‘stay down’ milk, or low allergy formula strikes me as companies exploiting an artificial niche in the market and evidence of benefit is very limited.

Medications fare no better. Antacids such as Gaviscon are frequently used, as are medicines that stop the stomach making acid in the first place, such as ranitidine and omeprazole (although this is an unlicenced use). When these medicines have been subjected to proper clinical trials they show that they reduce the acidity – but make no difference to how much a baby possetts or how irritable they are.

What is more, there are significant downsides to neutralising the stomach acidity in infants, in the form of increased risk of both gastroenteritis and pneumonia – presumably we evolved to have stomach acid for a reason, and keeping germs at bay may well be part of its role.

So, we have a treatment that doesn’t work, for a condition that doesn’t really exist, and that might make your baby really quite unwell – any takers? Let’s instead try to put reflux back into its box, let healthy babies be healthy babies, and reclaim the word possetting – more of a laundry problem than a medical one!

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