Colic and Reflux Virtual Group

Transcript

Understanding colic and reflux.

Hello and welcome to today’s understanding colic and reflux session. My name is Ellen DeCicco and we are part of a team which deliver your community health visiting service here in Lancashire.

In your journey to attending this online session you have probably been exposed to a world of information perhaps from the internet, friends and family or from healthcare and other professionals. Some of it may have been the same, some of it may have been different and unfortunately some may have contradicted each other.

We understand that this can be confusing and we hope this session will help you to understand the cause of why your baby is unsettled and ways to help them, but also where you can reach out for additional support should you want this.

We as health professionals are here to give support by listening to families experiences, drawing on evidence based information to help understand the causes of babies feeding discomfort.

When other professionals are involved working alongside them or involving them when necessary.

Over this session we’ll explore potential causes, these potential causes that are listed on this slide in more detail.

During this presentation we will be focusing on responsive feeding. This is setting your baby up for lifelong healthy eating habits and recognising that feeds are not just for nutrition but also for love comfort and reassurance between you and your baby.

To be responsive you can keep your baby close day and night, look out for their early cues and signs that they are hungry and look out for signs that they have had enough or full up cues.

So here are some common myths that we’d like to dispel. So babies tell they’re hungry by lots of different feeding cues, which we’ll go into more on the next slide.

Crying is the last cue and actually we don’t want to wait till they cry, we want to be picking up the earlier feeding cues because once a baby’s crying then we need to calm them down before we feed them.

Baby’s needs change hour by hour, day by day, and it’s not recommended that you try and get your baby into a routine from an early age. It’s really about being responsive to your baby’s needs and following their lead.

There’s a common myth that breastfed babies don’t need windin, and some breastfed babies will and some baby breastfed babies won’t need windin, But this myth can make people feel like they’re maybe doing something wrong if they have a breastfed baby who does have a lot of wind. If the baby does keep coming on and off the breast and there’s a lot of fussing at the breast, then winding may be a good idea. And if you are struggling, with breastfeeding getting somebody to check your positioning and attachment is always really useful and important.

How can we help our babies to be only having as much as they need? Paste responsive bottle feeding is the way to do this, so letting babies be in control of the feed as much as possible. We really really dissuade people from looking at the volume stated on the side of the formula tin and following these, because babies do not take a certain amount of formula every certain amount of hours. Babies need to lie cast, they change day to day, hour to hour.

Babies instinctively let us know when they need to be fed. If you know which signs to look for you can catch it early enough to prepare to feed baby before they become distressed. This is one of the many benefits of keeping baby close to you. When you consistently respond to those early feeding cues you are meeting their needs This will help them to feel secure and loved and to build their developing brain. The more the baby cries the more likely they are to have trap gas which can lead to colic. Babies need to be calm before they feed.

You can see some of the early cues there: staring, mouth opening, turning head, seeking and rooting, cooing, sighing, whimpering or making other little sounds, making faces, and then gradually moving on to becoming restless, squirmy, fussy, fidgeting or wiggling around when they’re showing they’re really hungry.

Looking out for these early and mid cues, can help you, avoid getting to the late cues when you really need to calm them down before you can feed them.

If your baby frequently sucks on their hands it does not always mean that they’re hungry.

From the newborn period hand sucking is not as reliable an indicator of hunger, and starting at around six to eight weeks baby will begin to gain more control over their hands and will soon begin to explore their hands and everything else goes into its mouth. It’s common for babies to suck on their hands when their gums begin to become tender in preparation for tooth eruption.

On the colic and reflux page on our website there will be a video cue, a video of cues from an older baby that can show, those older feeding, cues.

How do you know that your baby’s had enough milk? Falling asleep is a biologically normal response after a feed, when breastfeeding as long as it’s not the start of the feed this is fine.

With bottle feeding never coerce a baby to finish a bottle, let them be in control of a feed as you can overfeed from a bottle. So if we’re tipping the bottle up too much then the baby gets a bolus into their mouth and then we’ll swallow that bolus and then another bolus will go in and that will keep going. The slowest teats are best and allow baby to have plenty of breaks. It’s protected for a healthy relationship with food for babies to control the feed and be able to stop when they’ve had enough, and we will be looking at this in more detail later.

So here we have a definition of colic.

So your baby may have colic if they cry for more than three hours a day, three days a week for at least one week but are otherwise healthy. The important thing to know is that it’s a symptom of something else rather than a condition or diagnosis in and of itself.

It’s a common problem that should get better on its own and it’s not exactly clear what causes colic. It may be because some babies find it harder to digest food than others.

There might be times of the day when your baby tends to cry a lot and cannot be comforted. Early evening is the most common time for this to happen and the amount that babies cry tend to peak around seven weeks and then gradually tails off.

This is the newer definition of colic, that colic is growing with abdominal pain, and discomfort and not just any crying. So if you consider how you would act if you were to tummiate but you couldn’t communicate it and look for those sort of things in your baby, and this might help to narrow down whether the crying is due to a tummy discomfort or something else. So always seek medical attention if your baby’s not gaining weight or if the symptoms came on suddenly or the baby has a fever or rash. And there’s some other symptoms on this slide as you can see.

It may be that your baby lacks some of these symptoms on the previous slides that indicate that this, being unsettled is tummy related, for example drawing up the knees, and some of the other symptoms, in which case they might be crying for another reason.

Babies can’t tell us directly if something is making them uncomfortable.

Restrictive clothing could be upsetting for babies or you know it look at is their onesie too snug, can they stretch out their toes, Could their nappy be too tight? Are they too hot wearing too many layers or a hat indoors perhaps? Is there a scratchy label on their clothes?

If a baby is over stimulated it can help to change the situation and have a time out so go outside, take a walk, switch rooms, sing a song, have skin to skin or remove any kind of distractions possibly offer a feed, a warm bath or baby massage can also help.

Recent studies show that colic is twenty five percent more prevalent in the babies of cigarette smokers and mothers who have used nicotine replacement in pregnancy and breastfeeding suggests that there is an intolerance of the nicotine itself which manifests in symptoms of colic.

Babies prefer cold rooms to hot, they’re not good at regulating their own temperature so overheating poses a greater risk for infants.

If you’re able to stay calm this helps your baby feel more calm too and they can really pick up on our moods.

So if you are feeling stressed can you find some sort of stress relief? For example, you know exercise, going out for a walk, taking a bath, doing some mindfulness techniques. So look after yourself as a parent as well.

In ICON the C is for comfort and remember that some babies need more than others.

If it does seem like the tummy tummy related crying, then you know we can look at some other things. So hunger are they hungry? Obviously is one of the questions that we might ask.

Overfeeding so feeding large volumes with large gaps in between instead of little and often can stretch their tiny tummies and make them uncomfortable. So try not to be tempted to make them finish the bottle and look out for those fill up cues that we talked about before and let them control the feed.

Babies take in air either through crying or during feeding. It is more common for bottle fed babies to take in air but breastfed babies sometimes struggle when their mum has a fast letdown reflex or the latch could perhaps be better. Missing the early cues for either breast or bottle fed babies can mean that the baby gets upset and cries for feeds and this can increase the trap gas.

Reducing any trap wind is often the simplest and so first strategy, so try more upright feeding positions. We can see on the pictures here the koala hole for breastfeeding, with these blue, pictures and that can sometimes help, with a fast letdown or for the baby to be in more control.

Shaking formula powder can incorporate air so swirl it as you mix in it instead. Some mums value a vented teat that may also reduce air intake.

If breastfeeding speak with your health visitor or families and babies to come and watch your feed to see if they can provide any tips on how to obtain a deeper latch or better positioning.

Use the slowest teat of bottle feeding to help control the flow of milk. If breastfeeding some babies can struggle if mum has a fast letdown so whimping after letdown has passed can be helpful. If the baby slutters and chokes at the beginning of the feed allow him or her to come off and catch his breath first. Allow for pauses. Allow the baby to decide when the feed ends so they’re in control and look for those follow-up cues that we talked about earlier.

Keep them up right after feeds for thirty minutes, don’t put them down in a car seat or bouncy chair where they slump and try not to jiggle or move the baby too much as the feed settles.

This is an explanatory part of the slide about wonky winding.

Patting’s not needed here as this is a natural position for the trapped wind to come up on its own.

So yeah, so if you have the baby upright facing you with their tummy pressed against you, their bottom half in their middle of their body and their head on your right shoulder in line with your right shoulder leaning to their left, if you can see that picture there, then that can help some of the, in this diagram of the stomach some of the gas to come out. Over the counter remedies there’s a variety of things sold to help with colicky symptoms but they work in specific ways and address just one potential cause that won’t work for everyone. There is very little evidence that any of these treatments work but the current guidelines suggest parents could trial them for no longer than a week.

Reflux is when a baby brings up milk or is sick during or shortly after feeding and it’s normal for most babies. Reflux simply means something is going the wrong way through a valve. In this case it means that stomach contents are coming back up and out through the valve between the stomach and the oesophagus.

Because your baby’s oesophagus has not fully developed yet, because their bodies are new and immature and because we keep them lying down it’s very normal for babies to experience this type of reflux and some of course it occurs in most babies.

An estimated forty to fifty percent of babies under three months require to take their feed at least once a day and it is particularly common in pre serve infants, younger babies and those with neurodevelopmental disorders.

It can be helpful to remember that the stomach is a muscle like any other and so will grow and strengthen and mature over time. In fact research shows that the frequency of regurgitation declines over the first six months and dramatically after twelve months.

This interestingly corresponds with the time when babies can sit and stand therefore their stomach is less restricted.

Reflux is very common and usually gets better on its own. Your baby does not usually need to see a doctor if they have reflux as long as they’re happy healthy and gaining weight well. It only needs treatment if causing pain and or baby is losing weight.

Although reflux can be very messy it is often more of a laundry issue for parents than anything that we need to be too worried about.

Sometimes babies may have signs of reflux but will not bring up milk or be sick and this is known as silent reflux. Silent reflux is described as reflux where the regurgitation is swallowed rather than being spat out and babies may cry and show signs of distress but not puss it. Early weaning onto solid foods before six months is not usually the solution when it comes to a baby with reflux. A common hope is that if you introduce food to a baby before six months it will help with those reflux symptoms. The idea is that a thickening food in the stomach might help weigh the food down and prevent that regurgitation.

Unfortunately there is evidence to suggest that this can actually make things worse and so it is not recommended. Instead following many of the techniques we will share throughout the session can help manage the reflux until the baby outgrows it. Contacting your health visitor or families and babies to come out and observe a feed can help support you.

We understand that even though something may be normal it doesn’t necessarily stop it from being challenging and exhausting. Some simple changes can help reduce symptoms while you wait for the colic’s or reflux to clear naturally over time.

Optimising feeding is another key part of reducing the likelihood of childhood colic or reflux symptoms and we’ll go into this next.

So to optimise feeding and to hopefully prevent reflux and colic symptoms we need to feed responsibly so responding to those babies first cues and feeding them when they first show those signs. Feeding frequently, little and often is the key to digestive comfort as I think we’ve already said. For bottle fed infants ensuring your paced bottle feeding so sitting them nice and upright, tickling their top lip with the bottle, waiting for them to make that wide open mouth and holding the bottle as horizontal as possible, avoiding tipping up like that. Looking for full up cues, so perhaps baby’s starting to drift off to sleep, milk might be coming out of the side of the mouth or maybe they’re splaying their fingers or just looking more relaxed, they’re dropping the bottle down, sitting them forward and winding them and making sure so that we’re really pacing the feed and making sure that they’re controlling the rate of the feed.

For breastfed infants ensuring that you’ve got either your health visitor or one of the infant feeding team or one of our breastfeeding peer supporters to observe a feed and check your position in the attachment.

Please see the videos on our colic and reflux website page that look at good positioning and attachment when breastfeeding.

So what can we do to see the fractured baby and look after ourselves in the process?

So getting breastfeeding support if you’re struggling with positioning and attachment or maybe your baby is really unsettled after a feed is really good and families and babies are our peer supporters in Lancashire that can support you with that.

Holding babies upright and paced responsive bottle feeding is really important and holding babies upright for thirty minutes after a feed can really help with reflux.

There’s lots of different ways to wind a baby we’ve talked about some of them already but finding different ways that your baby is more comfortable is really good. We can see the tiger in the tree hold there and the hold which that doctor there is showing and these can be ways to settle babies.

White noise can be useful and also the washing machine is very useful if you’ve got a baby with reflux who’s making a lot of laundry. Baby massage is offered locally, it depends on where you live as to whether it’s free or whether you have to pay for it, so do ask your health visitor about that.

And slings can be really good, can help babies with reflux and colic and can help you as well because it means that you’ve got your hands free when they’re really unsettled and they want that hoarding.

So here we’d like to dispel some myths about poo. From week one until around six weeks of age we expect babies to poo at least twice a day breastfed babies and the poo should be at least the size of a £2 coin.

We don’t encourage you to give them cool boiled water giving babies anything other than milk under six months of age can cause tummy upset.

And if the baby is struggling to poo this indicates the need for a feeding assessment by somebody trained to do this like a health visitor or peer supporter.

If a baby is pooing frequently and the colour or consistency is different to what you would expect, for example brown or black, there’s mucus or blood in the stool or an offensive vinegary smell, this can be a sign of allergy or illness and warrants investigation.

The colour and consistency of poo is a really good indicator of whether there is any gut dysbiosis feeding issue or illness.

Green poo is usually nothing to worry about but if you spot other symptoms which are consistent with allergy or lactose intolerance, for example not gaining weight or not well in general, then get the baby evaluated by an infant feeding specialist.

Breastfed baby poo under six weeks is typically mustard colour and they’re sort of thick like liquid, corn resource, and often contains white seeds of undigested milk.

Variations of normal include shades of green and brown, although you may need to seek advice if your baby’s stools are more more often this colour than mustard yellow. Breasts for babies typically poo at most feeds until six weeks and anything less than two poos a day may indicate baby isn’t getting enough milk and to contact your health visitor.

After around six weeks milk composition changes meaning it becomes more normal for them to go days between dirty nappies.

It’s really important to know that stool output slows down around four to six weeks and this is completely normal.

Breastfed versus formula fed baby stool. You may notice differences in the stools of healthy breastfed versus healthy formula fed infants. Breastfed infant stools tend to be less smelly, looser, more frequently passed, but every baby is different. You may find that a formula fed baby stool has a consistency closer to toothpaste or that they strain and go red in the face more often. You might also find that a formula fed baby stool is a little more predictable.

The milk never changes so the stool often looks the same and is passed with a more similar frequency. A breastfed baby may initially poo more often and their poo may be more liquid like double cream but then slow down in frequency at around four to six weeks. Their poo may also be affected by what their mother has eaten. If a mother is eating something that has passed through her system very quickly then a baby’s poo is often more green. This is called intestinal hurry and is nothing to worry about. The digestive blood pick this can also happen if a mum’s nipple is bleeding during feeding and the baby swallows and then digests it.

Nappy output gives you a really good idea of whether the baby is well fed. Stool is really key to this. Babies will keep urinating until they are seriously dehydrated, so this is not a good early warning sign. A lot of people will get concerned if a baby has not had a poo for a few days.

Before we explore that it’s important that we understand what true constipation is as it seems to have become somewhat misunderstood. Constipation is the term used to describe hard pebble like stool not infrequent stool. If a baby only passes a stool every five to seven days but the stool is a normal consistency then this is not constipation. Many babies are prescribed suppositories or lactulose for so called constipation that is wholly unnecessary.

Think about how these drugs work. Lactulose draws water into the stool to make it softer and easier to pass. This is great if the baby is passing small hard pebble like stools that are painful to pass, but if the stool is already soft then this is entirely pointless.

Suppositories stimulate the rectum to contract. If the baby is just passing stool infrequently but normally then this will make the baby poo but it does not follow that the baby needed the medication.

So why might your baby not be going regularly? It is rare for a breastfed baby to be constipated as breast milk is considered a natural laxative due to how easy it is to digest. Constipation may occur with a formula fed baby however in a breastfed baby less than two poos a day before six weeks of age is a red flag that mum and baby should be seen by an infant feeding specialist. After around six weeks milk composition changes meaning it becomes more normal for them to go days between dirty nappies. Make sure you are making a formula powder with the correct amount of water. Water first followed by a level off scoop of powder with a formula fed infant.

But what if your baby seems distressed before they poo?

If the baby is healthy and gaining weight and feeding well then take any stool appearance with a pinch of salt. If the baby’s stool is unusual in the context of another problem such as weight gain, skin symptoms, reflux or irritability then have baby evaluated further.

The current definition for infant dyschezia where a baby turns red and makes a lot of noises before she makes a dirty nappy is straining and crying for at least ten minutes before successful passage of soft stools in an infant younger than nine months of age without any further health problem. This is often associated with infants turning red or purple in the face during defecation.

The explanation for this is a lack of coordination between increased intra abdominal pressure, preceding defecation and relaxation of the pelvic floor. Symptoms usually start in the first few months of life and resolve spontaneously after a few weeks.

Parents can be reassured that it is a benign condition and that the prescription of laxatives should be avoided. Dysgaea is often is under recognised and often mistreated as constipation.

The human microbiome is the collection of microorganisms which live on us and in us particularly in our gut. An infant’s microbiome may be altered from its intended form by the absence of biological norms such as vaginal birth, skin to skin contact after delivery and exclusive breast milk feeding in the first weeks of life, or the intervention of the use of antibiotics. It is thought that the altered microbiota may be responsible for the colicky pain experienced by some infants.

One of the most useful ways to manage microbial balance in the gut is to ensure that formula fed infant’s milk is being made up correctly to Department of Health guidance I. E. Fresh water in the kettle at least 70 degrees centigrade and making up feeds as you need them. This will reduce the risk of gut being overrun by illness causing bacteria.

If you have any concerns regarding lactose intolerance or cow’s milk protein allergy please speak to your health visitor.

So when we’re thinking about reflux most babies can be helped with first line interventions, soothing strategies and feed management techniques. For example smaller feeds, optimising feeding and many of the tips we’ve already discussed.

Then we move on to for those babies who this isn’t helping and who are having problems with weight gain or being really unsettled after feeds, there are allignant therapies so thickening either the milk or, adding Gaviscon, which, thickens the milk and stops that milk then, coming back through that sphincter at the top of the stomach.

Occasionally some babies may require acid suppressing medications so protein pump inhibitors for gastroesophageal reflux disease, and that’s something that you would discuss with your GP.

If you feel like you’ve tried everything within this session and the baby is still unsettled or you still have concerns please get in touch with your health visitor. We recognise that caring for a baby who is crying is hard work. Try and look after yourselves too. Do you have friends or family that could help out? Do you have access to community groups or peer support? Facebook can be great support for private groups on a variety of parenting topics.

Have a look at our website link which has all the references from today’s session.

Here are some other further resources families and babies they provide the peer support in Lancashire and the UNICEF baby friendly initiative website is always good to go to for up to date research and information on feeding.

The annual lactate app is accessible and there’s further information about this on our website.

Thank you for joining us for this session.