Wind, colic, reflux? an unsettled baby, what’s normal and how to help?
I'm often asked how, and when, to ‘wind’ a baby? I’m also frequently asked about colic and reflux and what to do with an unsettled baby.
All babies will experience some periods of fussiness in the early months. It's a very normal occurrence and shows that their digestive system is beginning to work. Wind may be released out of one end or the other. It's a whole body workout as they learn to coordinate the opening and closing of different sphincters. All of this is new to them, they’ve never had to do it before, and it may feel strange! They may bring their knees up, flex their hips, push down with their feet, clench their fists, frown, contort and change colour. In some cases, it may be dyschezia, a functional condition that can cause up to 30 minutes of crying, as a baby passes a normal soft stool. This is extrmely difficult for parents to watch, but it can be painless and doesn’t need any medication. Unlike adults, babies have a limited range of movements and can't easily adjust their positions or tell you what’s wrong. It takes a lot of coordination to poo! plus imagine trying to do so, lying on your back!
Infants have a range of behaviours and symptoms that make them appear unsettled, some normal and some that require more medical attention. The term ‘colic’ is now a frequently used phrase that is used to describe many things, including trapped wind, food intolerance, constipation, tummy ache, or something else.
As a parent, It's distressing watching little ones in pain, so it's helpful to have a term that names this. ‘But it is worth asking: ‘Does naming it also pathologise it?’
Traditionally, babies were carried and spent most of the day, uptight on a parent, meaning that they could feed frequently and food could easily be digested. Babies have immature oesophageal sphincters, that are designed to relax and open frequently, allowing the release of pressure from excessive feeds or any gas or wind to escape. Breastmilk is an amazing source of nutrition that also carries many microbes and anti viral and bacterial substances that bathe and coat mucosal surfaces - so a baby that regurgitates breastmilk gets a double protective coating. Sometimes, after positting milk, they lick their lips and, reminded by its deliciousness, ask for more.
Reflux
Reflux, is a normal occurance in a young baby. Its technically known as gastro-oesophageal reflux or GOR, and is the term used to describe the contents of the stomach going up into the oesophagus. Basically, something going the wrong way through a valve. It may come all the way up, and out, or it may come partially up, or be re-swallowed - silent reflux. A baby can easily bring up food if it has taken too much, or if there is any harm from keeping it down. If left lying on their back, and unable to change position, or if the stomach is full, food coming back up is physiologically normal and a protective process. Half the babies in the UK will reflux or spit up some milk at some point in the day. Some will bring up a little, and others much more, the frequency and consistency will vary widely. Its also worth remembering that a little bit of a spilt milk, looks much more dramatic than it probably is. Have a look at Lucy Ruddle explaing this here
Reflux disease (GORD)
Gastro oesophageal reflux disease, or GORD, is different from reflux, and is a medical condition that needs a proper diagnosis. According to NICE guidelines GORD should only be considered if a baby has two or more of the following symptoms:
Marked distress
Hoarseness
Unexplained feeding difficulties
Failure to thrive
Ear infections
Lower respiratory infections
Chronic cough
Wheeze
Green or yellow vomit
Blood in vomit
Apnoea
If your baby has any of the above please see a Health professional ASAP.
GORD is a serious medical condition, described as a reflux of stomach acid that irritates the lining of the oesophagus and is sometimes aspirated into the lungs causing inflamation, scarring and narrowing. Studies that have looked at this acid hypothesis, cast doubt that it is actually the cause of damage and pain. Nevertheless, its common to see babies prescribed strong medication, many of which can have long term consequences, and its questionable if it is actually needed. The tests needed to check if it is GORD are difficult and invasive. If a baby is failing to thrive then medication along with proper support is absolutely needed, but in my opinion it is often given without good reason. The medications prescribed however, still often use acid suppressing drugs like PPI’s (proton pump inhibitors) so we do really need some good studies to inform our practice.
Wind/burping
This randomised controlled trial looked at burping or winding as a preventative measure for colic and reflux, in healthy babies. It showed that actively patting a baby on the back did not significantly lower these events, but there was an increase in reflux episodes in those routinely winded. So, perhaps we are creating a so-called ‘laundry problem’ and wasting precious time patting babies, when we could be cuddling them and letting them gently fall asleep in our arms. Could we trust that they will burp if they need to?
Fussy symptoms tend to be more apparent in the evening, when it gets dark, say, from 6-10pm, sometimes known as the ‘witching hours’. At this time it is very normal for a breastfed baby to cluster feed. Often spending several hours going from breast to breast.
These times are more challenging, but are thankfully, generally followed by a relatively longer sleep. The baby will continue to feed several times throughout the night, but tends to manage to go back to sleep quite well, especially if feeding in the side lying position while bed sharing. In the morning, they often have a big feed, from a full breast, and then are relatively happy for the rest of the day, feeding often, and gradually becoming more fussy as the evening draws in. This behaviour can be very normal, and I see this pattern frequently in the first few weeks of life, sometimes lasting up to the third month when the baby’s gastrointestinal system matures.
However, some babies can be much more uncomfortable and the normal soothing from their parents doesn’t seem to help. They may cry for long periods, have unpleasant smelling gas and frothy smelly stools. These babies are labelled with colic, the Greek word for colon, described in 1954 by Morris Wessel as ‘persistent crying for more than three hours a day, for at least three days a week, for at least three weeks in a row’. Devastating and very painful for babies and their parents.
Some colicky symptoms may be relieved by the way the baby is feeding.
It may be their latch, to the breast or bottle, the way they are being held, the flow of milk, or supply. It can also be a misinterpretation of a baby’s cues, due to unrealistic expectations of normal baby behaviour. I have seen many babies getting upset because they want to feed or have a cuddle, but in a society that informs us that babies should be on a three hourly schedule and shouldn’t be spoilt, this signalling can be easily read as pain or colic. This can then cause more upset in the baby and parent and cycle more stress and nervous system activation. An IBCLC and a CST therapist can help with these things and I would always recommend checking in to see if they can support you. Here is a study that looks at how CST - craniosacral therapy helps reduce the number of crying hours, colic severity and increases sleep.
Dr Howard Chiltern,a neonatologist, believes that colic is a symptom of overwhelm. He suggests that some babies struggle with being born evolutionary premature and often feel like they need to be back in the womb. ‘Colic has never been about pain in the abdomen or anywhere else for that matter. There is no question that the baby looks like he or she is in excruciating tummy pain. The baby doubles up, knees in chest, and screams like there’s a knife twisting in his gut. But it’s not about pain, it’s about stress and overstimulation of the poor baby’s sensory nervous system’. He discusses how holding them close and helping them to feel womb like can be ‘the most important lesson to learn : how to keep themselves calm and feel secure’
This is a great article that looks at this fussiness in the early months, often called the fourth trimester, and suggests ways to help comfort your baby and make the world feel more womb-like.
The type of milk a baby receives, breastmilk or formula can contribute to gas.
It depends on the different enzymes in the milk and bacteria present in the gut to digest it and break it down. This process can create pressure and both hydrogen and methane are among the gases that can contribute to this. Some gas will be easily released, while some may be trapped and move around in the gut, creating discomfort or pain. There have now been a number of studies that have identified a difference in the gut biome (dysbiosis) and gasses present in babies with colic symptoms, like this one and this one.
Gas or wind, can be caused by fermentation and digestive processes in the intestines. This is a normal action of healthy bacteria breaking down food particles, like milk sugars and human milk oligosaccharides (HMO’s). Lactose, the main sugar in breastmilk, is important not only to brain development, but also the prevention of infection. If you have an abundant milk supply, there may be too much lactose for the baby’s gut to absorb. It can leak into the colon and ferment, producing lots of hydrogen gas and liquid poos.
These microbial colonies are a vital component to our health and well being and are known as the gut ‘microbiome’. As adults we have about as many bacterial cells as human ones and the more we learn about them the more we understand about our health and immunity. For example, HMO’s are not digested by the infant and pass whole into the large intestine where the majority of bacteria are found. They act as a prebiotic and encourage the growth of good bacteria as well as blocking pathogens and viruses. We each have a unique microbiome that is established in the early months after birth, through inherited bacteria, as well as those digested and from our environment.
The first barrier to microbial infection is stomach acid.
The breastfed baby’s normal stomach pH is sufficient to kill most pathogens. The child who is not breastfed has a less acidic stomach pH, allowing more bacteria to survive its journey into the intestines. Some of these rogue survivors, can multiply in the stomach and ferment food, producing gasses and alcohol as a result! Therefore, medication that neutralise stomach acid can actually increase the danger of infection. Medication that suppress stomach acid are sometimes required, but should be prescribed with caution. Many manufacturers advise against giving them to children as they have not been thoroughly researched.
Parents caring for an unhappy baby may be pleased to hear that for most it will get better at around 3 months of age. Helping to make the babies environment more womb like in their transition into the world can help a lot. Holding them upright on your body, or in a sling, white noise, gentle jiggling and rocking can make a difference. Warmth and gentle abdominal massage can be useful, as can a warm bath together. Feeding support from an experienced practitioner will also help you to understand if there is anything about the way they are fed that will help. As a parent, I would urge you to get help, to support you during this difficult time, so that you can be more available to help your little one. If you don’t have friends or family close by, consider looking for a postnatal doulas.
If you are concerned, please see your GP or paediatrician for a proper diagnosis and testing, if your baby has severe symptoms they may benefit from medication.
Here are some of the more common ones prescribed:
Carobel or thickening agents
Commonly made from carob or locust bean, rice cereal, corn starch, maize starch, xanthan gum or pectin. Attempt to make the milk heavier to sit in the stomach and not reflux into the oesophagus. Comes in powder form and has to be mixed with milk and fed via a bottle. There is little evidence to support this as a medication. It can be hard to make up and give effectively and can cause constipation.Gaviscon or alginate therapy
Sodium alginate is mixed into milk to give to the baby. The theory here, is when the alginate meets the stomach juices, it forms a a thick gel like solution. It also creates CO2 in the stomach, which causes the alginate to float, raft like, and prevent regurgitation. Again the evidence is low and alginates may cause side effects. A study suggested it may trap fats and fatty acids and reduce bile and iron absorption. There are also studies that site its use as an appetite suppressant in adults, so potentially dangerous for a baby with slow weight gain.Acid suppression therapy
PPI’s like omeprazole, lansoprazole and esomeprazole stop the parietal cells from pumping out hydrogen ions and prevent them producing hydrochloride acid (stomach acid)H2 (histamine blockers) Please note that Ranitidine is not currently dispensed worldwide due to concerns over potentially harmful ingredients.
Block histamine and therefore the creation of stomach acid.
Both the above do reduce acid, but studies have found that they don’t prevent crying or reflux symptoms, perhaps, suggesting that it's not caused by acid.
These medications have side effects: headache, stomach pain, wind, constipation, diarrhoea, nausea and vomiting.
They are also not recommended for use with infants. Several studies have also found that these drugs can cause respiratory infections, fractures, pneumonia and gastro-intestinal infections in adults and older children. There is also discussion about the long-term consequences of omeprazole on osteoporosis.
Worryingly, there is also research that suggests acid suppression could affect the development of food allergies
Stomach acid is essential to break down proteins, which are common antagonists to allergies like CMPA – cows milk protein allergy.
Acid suppressants need to be reduced slowly to not cause a rebound effect and stimulate excess secretion of acid making symptoms worse.
Remember that stomach acid is our first barrier to microbial infection. A breastfed baby’s normal stomach pH is less than 4, making it sufficient to kill most pathogens swallowed.
Infacol/simeticone or Dentinox/dimethicone
Helps by reducing the surface tension of trapped gas by joining them together.Colief/lactaid
Lactose drops help to break down lactose in the milk if there is too much or if the the baby has reduced lactaseGripe water/woodwards
Contains dill and sodium hydrogen carbonate (bicarbonate of soda). May taste nice but little evidence to suggest effectiveness in trials.Probiotics
Recently ‘baby probiotics’ have become popular. They contain strains of bacteria that claim to have an effect on the babies microbiome. To know effectively which actual strains are missing from a baby they would need their stools to be analysed. If a baby is breastfed, breastmilk will provide the right bacteria for the baby along with prebiotics, for the good bacteria to eat. It seems strange to give random bacteria to a baby when if it was needed at all, it could be taken by the mother and be passed on through breastfeeding.
Some products have been specifically made and targeted towards breastfeeding babies. However this has received criticism because actually the mother’s milk can provide all necessary bacteria as well as the prebiotics for the friendly bacteria to eat, if the mother’s milk contains them. So with the breastfed baby, the wisest course of action would be to supplement the mother, not the infant. And with a far broader spectrum product than that.
If you have a baby that is unhappy, ‘sicky’ or uncomfortable, please seek support to see if it is feeding or allergy related, or physiologically normal before you consider any medication.
Further sources are thanks to Carol Smyth for her book ‘Why Infant Reflux Matters’ and the Babyem course on infant allergies, reflux and colic.
If you need support to help you with an unhappy baby, please contact https://www.cry-sis.org.uk/
