Reflux vs GERD with Dr. Janet West
Hey there! I’m Becca Campbell, your pediatric sleep consultant and this is the Little Z Sleep Podcast, where I am committed to resolving your child’s exhausting sleep habits. This is episode 48 and I am interviewing my friend, Dr. Janet West of My RVA Baby and we are getting into reflux and GERD because did you know every baby has reflux? Yeah! Every baby has reflux, but only some babies have GERD. These are some things we are discussing on today’s episode, as I walk through what is reflux versus GERD, but even more so, what are some ways you can be proactive, talk to your pediatrician and get some management for your baby’s GERD, and reflux. What I love even more about this episode is that Dr. West doesn’t just have twenty years of experience with this, she also has a daughter with a very severe case of reflux, and so it was so fascinating to sit down with her and just walk through what to expect and actually talk about in a candid, unprompted, she had no idea I was going to ask, what do you think about reflux and sleep? So, it was really cool to talk to her about that.
Now, before we get into today’s episode, I have a review from a mom with a baby who has GERD, and guess what? He’s sleeping great, so I want to read Caitlin’s review for you guys:
Becca’s e-coaching worked so well for our stubborn four-month-old with GERD. At night she slept in a roc-n-play and for naps she needed to be bounced and held. There was no putting that baby down. When she started fighting being bounced too, we knew we had to do something. Becca’s program was easy to follow. Her podcasts are super helpful, as are Q&A days on Instagram. It only took one tough night for our baby to get it. Night two, she slept nine hours straight, woke up for a feed, and slept two more hours. Having her nap in her crib and not in my arms has been life changing. Her e-coaching was so easy to follow that I was able to do the whole two-week course, by myself, while my husband was away for military training. Seriously, you can do this. If you are a super worried, first time mom, with a baby who has GERD, they can do it too. Our girl is a happy baby getting the sleep she needs thanks to Becca. If you’re on the fence, just do it.
Caitlin, thank you so much for your kind words, but more so for your patience, consistency, and hard work with your sweet little girl because you also left your review with some pictures, and she’s adorable! You guys, wherever you are in the world, however old your baby is, sleep is a thing, and we can make this possible, so I want to encourage you, we have about two weeks until Valentine’s Day, and what an amazing Valentine’s Day gift to be able to hand the monitor off to the babysitter, or have someone else put your little one down because you know they’re going to sleep wonderfully through the night, or like Caitlin’s little one, have a plan for one night-time feed. Guys, this is so possible, and I can’t wait to welcome you into sleep e-coaching. We have courses from four to sixteen months old, toddler coming soon, and I just want to encourage you that sleep is possible.
Guys, I am so excited to welcome Dr. West today as we discuss all things reflux, GERD, and sleep.
Becca: I am really excited to have Dr. West back because you are actually my first repeat guest. We chatted almost eight months ago on how to choose the correct pediatrician for your family and that was really great insight and I loved that and I know our listeners did too, so I brought you back today because I am getting lots of questions, and yes some push back still, about “Well I can’t make change with my baby’s sleep because they have reflux”, and I do find that it’s just being thrown out as an excuse for lots of different things, and I thought the best way to tackle this is to have you and I sit down, as someone who obviously has a lot of experience with newborns, yes, but with babies and families, so I am excited to talk about that, but real quick, could you give us a little snapshot of you and your experience and what you do?
Dr. West: Okay, well thank you again for having me back. I’m happy I’m the first repeat guest. That makes me excited. A brief overview of me and what I do, I have been practicing pediatrics now for twenty years, and I have a lot of different experiences, primary care mostly, but here recently I’ve moved into the newborn care with RVA Baby, so my practice is really focused on helping families transition through that fourth trimester, get to know their babies, and get through all of the challenges that you have when you have a newborn coming home. Sometimes I’m working with moms on their first baby, sometimes it’s baby seven or eight because everyone is different.
Becca: Amen! Amen!
Dr. West: The beauty of what I do is I get to do it at home. I get to see the family in their element, where they’re most comfortable, but also where they’re most vulnerable. I feel like I can help them and support them more effectively because they’re just more open. They’re just more comfortable and we can develop relationship and connect. That’s what I do. The interesting thing is, is that most of the babies that I see have graduated from my practice by the time they’re one to two months old, so by the time they get to you and they’re talking about reflux, you know, they’re sort of out of my reach. They’re back in the hands of their newly selected primary care pediatrician and going out to the office. It’s great to be able to shed some light on this and be able to talk about this topic with you.
Becca: Yeah, I’m excited about that, and as a little plug, I have a very large Richmond based listenership, and if any of you out there listening are pregnant or about to have your baby, you need Dr. West because she comes to you! Like you just said, who wants to take their child out when they’re first born to the doctor? No, no! Let Dr. West come to you! RVA Baby! Love it!
I want to dive as deep as we can in this time for reflux and kind of go through some things, so just to walk through what we’re going to talk about today, ya’ll, we’re going to talk about what is reflux? There are degrees and variations and what do those look like? What does it look like to diagnose your baby who might have reflux? We’re going to discuss tactics for managing reflux and how to really look at reflux as they age. So, beginning with the term reflux, what is reflux?
Dr. West: Let’s think about it historically. Historically, whenever people have a baby, they always have a burp cloth, right? They always have a spit cloth or little rag because babies are just spitty. Some babies are a little spitty, some babies are a lot spitty, right? Reflux is just that process of milk washing up from the tummy, up into the esophagus and out of baby’s mouth. Sometimes it doesn’t even come out of their mouth, but it might come to the back of their throat, and that happens in most babies because that little muscle between your stomach and your esophagus just doesn’t have a lot of tone, so when we think of reflux or spitting up, that’s really a normal thing for babies to do.
So, we have to differentiate reflux from the pathological term that we use, which is GERD. So, GERD is an actual disease. Gastroesophageal Reflux Disease. I feel very comfortable in saying almost all babies have reflux. That’s just how they’re built. When they have Gastroesophageal Reflux Disease, that means that reflux is severe enough that the baby is not thriving. When I say not thriving, it means that baby is not gaining weight effectively because they are spitting up more than they are able to retain, that baby is having esophageal damage and irritation from those stomach acids, so it’s painful for them to eat, or they’re upper airway is getting irritated from those stomach acids, so they’re hoarse, they are getting this nasty taste in their mouth all the time, and they’re just uncomfortable and fussy and can’t settle. Reflux, all babies have it. GERD, not so much, GERD is where we’re looking at intervention.
Becca: You mentioned when we first chatted, on the phone awhile ago, about this conversation, you mentioned that your daughter has really severe reflux, so is it either all babies are spitty or you have GERD, or is there more degrees off of GERD?
Dr. West: There are more degrees off of GERD. Some babies have Gastroesophageal Reflux disease, like I said, and just have a little irritation in their esophagus and those babies do well with either an acid reducer, like Zantac or something like that, to increase the acidity in the stomach, so that milk that’s washing back up isn’t irritating as much. Those medicines don’t stop the baby from spitting up. It just calms the irritation down. Sometimes they’ll recommend thickening the baby’s milk, and in those cases, maybe those babies don’t have as much irritation, but the volume that’s coming up is excessive. So if you thicken it, the idea is that it’s less likely to wash back up because it’s more viscous, it’s not as likely to come back up through the esophagus, it’s more likely to pass through their gut, and move on out of their stomach, so they’re not spitting up as much. But when we look at variations of GERD, the severity can be from just needing to thicken the cereal, or I need to feed more frequently with smaller feeds, more often so my tummy doesn’t get as full, so I’m not spitting up as much, or I need medication. In severe, severe cases, there might be a need for surgical intervention. Some babies have gotten to the point where they need surgery to tighten that area up, and even get g-tubes because they’re not growing, at all. That’s extreme and very rare for babies to have severe failure to thrive from reflux.
My daughter had failure to thrive, but she did really well with medication and she had to have thickened formula. It was a projectile feed every time she ate. It would go down and come right back up. As she got older, she continued to have reflux. As a toddler, if she ate too much, she would spontaneously just spit up all of her food. It would just come up, and she was the littlest thing. She was in kindergarten in a 4T, and I remember struggling because I was excited that she was going to get to ride the school bus for the very first time in Kindergarten, but she was so little, she couldn’t get up on the first step, so they said she couldn’t ride the bus, because she couldn’t get on without assistance. So, yeah, that was heartbreaking. You have to be able to get on and off for safety reasons, right? So, as she got older, it was just a matter of teaching her how to manage it. How to eat, when to eat, timing and things like that. Now, in her twenties, she still struggles with it, and has to learn how to continue to manage that. Most children will outgrow their reflux. Most children, if they’re on medications are off of those medications by the time they’re a year old, or even sooner because they’re eating solid food. They’re not on a primarily liquid diet, so they’ve grown, their body’s matured and they’re eating things that aren’t likely going to wash back up. For the majority of the folks out there, their reflux is going to go away, and it’s not going to be a lifelong issue for those children. Until they reach middle age like me, and then that’s a whole new thing!
Becca: So let’s assume someone’s listening to this podcast thinking, “Okay, yeah my baby is doing more than just spitting up, they do seem irritated”, what are the steps for diagnosing GERD or any variation of that?
Dr. West: In most cases, you’ll go to your pediatrician, and they’ll have a conversation with you about what those symptoms are. A lot of pediatricians will ask you questions like, Does the baby pull away from the bottle or nipple when they’re feeding, which can be a sign for discomfort. Do they start eating, then stop and cry? Are they irritable all the time? So outside of your normal colic, or your witching hour, you know have you tried all the things, but you just have a baby that’s irritable, especially around eating. Are they developing food aversive behaviors like acting hungry, but just don’t want to eat? You can diagnose reflux based on that, really, and implement a trial of medication and if that medication works, and baby gets better, then you’re good to go. In many cases, you can do it without doing anything invasive.
Other studies that can be done, and the most common one is something called an Upper GI, which is an exam where they have baby swallow a dye, and they look to see how that liquid goes to the stomach and then they look to see if it washes back up into the esophagus, and how far back it goes. It can go halfway, it can go all the way up to the vocal cords, but they can take a look at that and see how fast and how much of that liquid comes back up into that baby’s upper esophagus, and that’s another way to diagnose it. The problem with that system, is sometimes babies can have reflux, but not reflux at that moment in time, so there are lots of babies that are actually getting treated, but have had a negative Upper GI study, but have responded well to treatment and their symptoms have gone away. That study is the most common one.
There is another study where they can use a PH probe to see what the PH is. Is the PH in the esophagus really low? Is it really acidic like there’s acid washing back up in there? That’s a little bit more invasive, and less commonly done. It’s more reserved for your extremely severe cases where they’re thinking maybe some surgical intervention may be needed. For the most part, though, you can treat and diagnose based on symptoms and how that baby presents and responds to medications. If that doesn’t work, then your pediatrician will take the next step and send you to the gastroenterologist for one of those Upper GI studies.
Becca: So I know having worked with lots of first time parents, and being once upon a time a first time parent myself, do you feel like because we need to evaluate the spitty baby versus the GERD baby, and all these things, if you just mentioned a couple of quick symptoms about pulling away and things like that, is there a certain amount of time we need to see past, not like the first time you see baby back away from the bottle, what would be your word of wisdom for these first time parents when they’re trying to figure out if this is just spitty baby or maybe something more?
Dr. West: You know, it’s hard to say, because it depends on the parents’ tolerance level. Right? My recommendation would be if you notice something and you’re uncomfortable with it, go have a conversation with your pediatrician, because they can look at the big picture. If you see those symptoms and it’s only been a short time, but your baby is really struggling with gaining weight, maybe it’s time to act sooner than later. But if you have a big, chunky baby, and they pull away, maybe a couple feeds a day, it could be that you just have a really fast let down, but that baby is growing, they’re happy otherwise, that would be a baby where I would just take your time, watch and wait. That’s a conversation to have with your provider. I always say, if there’s something that you’re concerned about, don’t ruminate on it, go check in. It may be that you do nothing at that visit, just say I have a concern, this is what I’m seeing, should I be concerned? Then you can have a conversation that will be reassuring and give you a timeline of how long to expect to watch those symptoms before you go back. It’s about that partnership. Don’t hold back, share everything.
Becca: I love that, and gosh, I’m such a good spokesperson for you Dr. West because I’m already thinking about, I know we’re not talking about reflux in a newborn stage, but I mean how great would it be when they’re at any age to just text your doctor, right? Well, you could text Dr. West! I love that! I think about that and it would have been so awesome as a first-time parent to be doing that. Such a good plug for you again!
You’ve mentioned a couple of tactics for managing reflux, and things like that. When we discuss tactics for managing a child’s reflux, are these things that we can look at a list and try things on our own, or are these things that we need to ask the pediatrician about? Walk us through some typical tactics and what we could try.
Dr. West: So, for just the reflux or the spitting, there are a couple of things you can try. First of all, when your baby eats, it could be a little positional, right? They’ve got a full tummy, you lay them down flat, they might be more likely to spit up. The first tactic, then, is to try to keep them upright for a little bit after they eat. That’s the more common thing. That’s a good time to have some wake time with them. You can have them at a 45-degree angle, you can have them sit up on your chest and have the prop their elbows on you, and look at them a little bit. Keeping them upright as much as you can for about thirty minutes after a feed is a good way to minimize that. Especially if you’re breastfeeding because breastmilk moves through really quick, so you’ll feed, that milk will go through, and you should see lower volumes of spit up. For formula, that baby’s formula tends to sit in the tummy a little longer, so it’s more likely to wash back up the esophagus. Same concept. Try to keep them upright a little bit after they eat.
Taking a step back, always keep a little burp cloth on hand! It’s a good way to go for a lot of moms, that constant spitting up seems like a huge volume, but try to think about if you poured a teaspoon of water or tablespoon of water on that burp cloth, what would that look like? Not as much as you think. You think it’s a whole feeding, but it really isn’t. In the grand scheme of things, it’s just a little bit. I encourage families not to get too anxious about the fact that their baby is spitting, especially if everything else is going well.
One of the first things you can do is keep baby upright, and then if you have a baby that is bottle feeding pumped milk or formula and that baby is two months old, but you’re giving them six ounces, you’re probably over feeding. Avoiding over feeding is key! Babies don’t have an automatic shut off valve, so they’ll eat until it’s coming out of the side of their mouth, so make sure you’re not overfeeding your baby. If you’re feeding your baby and they’re spitting up after feeding, but then they still seem content, they’re probably spitting up that excess. Have a conversation with your doctor about what’s appropriate for your baby to eat at that age. I hear moms say their one month old takes an eight-ounce bottle, you know! Then you look at the baby and the whole front of their shirt is yellow! You know what’s going on there, so avoiding over feeding is another thing you can do. Be mindful of that as you are feeding your baby as well.
Becca: I’m glad you brought up the amount they might spit up because I do hear that from parents a lot at the bedtime feed, that “My child spits up half the bottle!” I think, “Are they really?” I doubt they are really spitting up the whole thing, and that’s such a good visual check, is to go to your kitchen, get a tablespoon of water, dump it on the burp cloth and evaluate that it’s a lot more than you think.
Dr. West: I actually had an old pediatrician who had a trick. He would tell the parents to get a cup of water, put some food dye in it and pour it on a towel and see how much that is. It will give you a good idea of how much your baby is spitting, and it’s not a whole feed. For those babies that it is a whole feed, then you can know maybe my baby is spitting up a whole feed, so go to the next step.
Becca: Such good thoughts. I want to be looking at reflux as they age, some things that maybe as parents we should have a checklist of because it’s one thing to say at maybe six months old they get diagnosed, they get on the medicine, how should we be looking at reflux as they age? Do we always need to be evaluating, do they still need the meds, do they not need the meds? Walk us through that path of baby has been diagnosed, here’s what we do, now what’s next?
Dr. West: The trick that most pediatricians use is they will continue to treat with medication, and because the medication is weight based, they will not increase the dose, they will let baby gain weight. If those symptoms start to look like they are trying to come back, then they will adjust the dose up for weight. Usually what we do is let them outgrow the dose, and then just discontinue the medication altogether, which is a really neat trick, because if the dose isn’t therapeutic, we know they don’t need it anymore, and usually by the time babies are nine to twelve months, they’ve outgrown that dose and we can stop the medication and then we just move on with life.
For those babies that seem to continue to need that medication, usually as they are getting a little older, a lot of times pediatricians will say let’s go have a visit with the gastroenterologist, maybe it’s time to do an Upper GI or take another look at what’s going on with your baby, but the overwhelming majority of babies, you’re just going to let them outgrow that medication.
Becca: I love that! It’s definitely something that always needs to be evaluated by them. I do hear parents kind of self-diagnosing things sometimes.
I would love to hear any of your thoughts on sleep habits with reflux, because I hear things all the time about baby not being able to sleep because they have reflux. It just doesn’t quite connect, so I would love to hear your thoughts on that.
Dr. West: The only correlation I could see is in that early period, if that baby had severe reflux and they were just irritable all the time, then maybe that baby didn’t settle in sleep well, but if that GERD is being treated adequately, then there should be no sleep disruption, you can take on any sleep plan or treatment that you need, if you want to work on sleep or a sleep schedule. It shouldn’t interfere at all. If that baby is not able to sleep well because of those symptoms, then maybe you need to go back to the drawing board and look at treatments. There are levels of medications that you can use if the basic Zantac doesn’t work. Maybe you need a Nexium or something that’s a little bit stronger. Otherwise, there should be no sleep disruption, really.
Becca: I’m with you! I’m with you on that! Surprise!
Dr. West: My thought would be that the symptoms aren’t adequately being treated, or that parent is still in this smaller, frequent feeding cycle, and that can be tricky, but depending on the age of your baby, what they’re eating and the volume of food they’re eating, I still don’t see where that would have any major bearing on sleep, right? If you have a newborn and they’re eating every three hours, or a four-month-old that’s eating every four hours or four to six hours, those intervals are sort of appropriate anyway for them, so I feel like you should be able to take on any sleep training you need.
Becca: I’m so thankful for your insight, and I know this was a good 101 on reflux and GERD and I really know that everyone listening has a much better understanding of it, and me too! Neither one of my littles had GERD, of course they were spitty, but not that, so it’s always good to have an insight, so thank you so much for being here! I would love for you to tell our listeners, especially if they are here in Richmond, how can they get in contact with you to have you be there initial start for their baby’s primary doctor in the beginning.
Dr. West: I have a website, www.myrvababy.com, you can find me there. There’s a place where you can fill out the contact information. I’ll get an email and get back with you. You can also find me on Facebook at RVA Baby, and on Instagram @myrvababy on Instagram. You can message me through either of those social media platforms. Or you can just give me a call at 804-762-3009 and I’ll call you back!
Becca: I love it! Well thank you so much for being here! I love your wisdom and insight. I’ll never forget when I was covering in the newborn course, you have a bonus in there for me about newborn things, and one question I got was should I take my baby to the beach, and you said, “Babies are in jungles, you take that baby to the beach!” I thought, “Yes! I love her!” I just love your take on things for baby, life, and mom, so thank you for being here!
Dr. West: You are so welcome! Thank you for having me, as always!
I’m so thankful that you were here today and listened to this really insightful wisdom from Dr. West. I just really can’t get enough of her, she is so wise! I just love her realistic edge about things, and I’m grateful that you’re here for this! Join us next week as we look at more sleep topics because you know what, I’m here every week to resolve your little one’s sleep habits. Whether you’re interested in getting started through e-coaching or you just want to connect through this podcast every week, or work one on one with me personally, I am just grateful that we are all here making sleep happen. Sweet dreams! See you next time!