Is burping really necessary? Grandma versus science!

The Pediatric Insider

© 2016 Roy Benaroch, MD

Ann wrote in: “My baby doesn’t burp easily – sometimes she doesn’t burp at all. Trying to make her burp makes her upset. Do babies really need to be burped after nursing?”

A fair question. Generations of parents have been burping their babies, and it seems like something we probably ought to do. I mean, it’s uncomfortable to have un-burped gas in your belly, right? And gas there probably causes fussiness, and maybe makes babies spit up, right? Not only does it make sense, but that’s what Grandma has been saying. Could Grandma possibly be wrong?

Let’s see what science says. There was a study of this exact question, published in 2014 in the journal Child: Care, Health and Development. A group including nursing and pediatric specialists from Chandigarh, India took on the Grandmas in their publication, “A randomized controlled trial of burping for the prevention of colic and regurgitation in healthy infants.” Their conclusion: “burping did not significantly lower colic events and there was significant increase in regurgitation episodes.” Yikes!

It was a simple study design, the kind I like best. 71 babies were randomly placed into two groups: an “intervention” group, where moms were taught burping techniques and told to burp their babies after meals; and a “control” group, where mom were taught other things about parenting, but were not taught about burping. The babies were all otherwise healthy, ordinary term infants, enrolled shortly after birth. They were followed for three months, with the families recording crying times and the number of spit-ups (regurgitation.)

The results: the amount of crying in each group was about the same. Burping did not prevent “colic”, or excessive crying. When comparing the episodes of spit-up, the “burping” group had approximately twice as many spit up episodes as the non-burped babies. So: burping had no effect on crying, and actually made spitting worse.

There are some important limitations. The study was done in India, and the conclusions might not be the same in babies from other parts of the world. Also, the intervention wasn’t “blinded” – for practical reasons, the parents knew if their babies were in the burping group. Still, the conclusions were statistically strong, and I think they’re probably correct.

Will this convince anyone to stop burping babies? Probably not. But I would say, for Ann, if burping makes your baby upset, there’s no reason to keep doing it. For the rest of you: you’ll have to settle this with Grandma, yourselves. I’m not getting in the middle of it!

Reflux and babies: Ineffective treatment of a non-disease?

The Pediatric Insider

© 2016 Roy Benaroch, MD

Heather wrote in:

As a postpartum doula for the last 12 years I have seen something in the last couple of years that I would love your insight on. At least 30-40% of all the babies I care for now have reflux/GERD diagnosed. Roughly 25-30% are on daily meds for this. Parents go to the DR to get some sort of help for fussy babies and take home a prescription for GERD. Reminds me of when my kids were little and we got RX for antibiotics for so many things.

Heather’s right. Reflux (or GERD, gastroesophageal reflux disease) has emerged as a modern boogeyman, blamed for all sorts of symptoms in babies. The bottom line: most babies thought to have GERD don’t have it, and even among babies who do have GERD the medications used to treat it don’t seem to work.

Some background: “gastroesophageal reflux”, abbreviated GER, is the involuntary expulsion of stomach contents up into the esophagus. Stuff comes back up. All babies, and this is no surprise to parents, spit up, and most of them are perfectly happy to do it. Those “happy spitters” are easy to identify – they have no symptoms at all, no fussiness, they’re gaining weight, everyone is comfortable – and there’s really no controversy that these babies with “GER” need no treatment.

But there’s another abbreviation, GERD, for “gastroesophageal reflux DISEASE”, and that’s when things get murky. GERD = GER + D, or reflux that’s causing symptoms or problems. We’ve thought, for instance, that reflux could cause babies to be in pain. That makes sense, because many adults experience heartburn pain when they reflux. Though babies have less stomach acid than adults, they have some, and you’d think at least some of them might develop pain and inflammation in the esophagus from acid splashing up there. There are other symptoms, too, that have been blamed on GERD, like breathing problems or poor growth. And these do happen – GERD is a real thing.

Problem is, when it comes down to objective testing, it’s very difficult to tell whether GER is really causing the D in an individual patient. Yes, Junior is spitting – we can see that, it’s on the floor and all over dad’s shirt. And yes, Junior is fussy. But does one really cause the other? Does treating GER really help the symptoms we’re blaming on the reflux?

A study from the April, 2016 edition of the Journal of Pediatric Gastroenterology and Nutrition tried to help figure this out. They used a state-of-the-art diagnostic tool, a multichannel intraluminal impedance study, on 58 infants suspected of having GERD. Most of these babies had irritability as their main symptom. Of the 58 babies, only 10% ended up having an abnormal study – only 10% actually had reflux. And, among the babies who had episodes of irritability during the study itself, only about 20% had reflux during their symptoms. Reflux, when measured objectively, is uncommon even in babies who have symptoms we think of as reflux-related. And even during the symptoms, reflux usually isn’t occurring.

Do GERD medications, which primarily work by blocking acid secretion, even work in babies? The evidence, as reviewed by Jay Hochman in his pediatric GI blog,  says “no.”

It’s a conundrum. My gut feeling (ha!) is that GERD really does occur in some babies – but not often, and certainly not in most babies evaluated for fussiness. And if there isn’t GERD in the first place, of course the medicines for GERD aren’t going to help. There’s a strong placebo response rate in GERD studies of infants, so maybe to some degree an expectation of relief helps parents deal better with their babies’ fussiness. Or maybe the meds do work in the real cases of GERD, if diagnosed correctly in the first place. It’s just hard to separate all of this out, because the symptoms are so common. And those little babies don’t talk yet, so we don’t really know if they’re in pain, or where the pain is coming from.

Babies with excessive fussiness need a medical evaluation. Some, but not most, will have a specific medical explanation for their crying, and sometimes treatment helps. Many have more of a temperamental or developmental fussiness, and need to be held, and need reassured parents with backup support and a few good nights of rest to catch their breath. Medications aren’t always – or even usually – the answer.

What really works to treat infant colic?

The Pediatric Insider

© 2014 Roy Benaroch, MD

Colic is not fun.

You’ve got your little wee baby home, and you’re exhausted. Just when you need some rest the most, Junior cries. And cries, and cries. And nothing seems to help for more than a few moments.

Colic has a medical definition, sometimes called “Wessel’s criteria”: inconsolable crying in an infant less than three months of age, for at least three hours a day, for at least three days a week, for three weeks or more. I doubt many practicing pediatricians or parents rely on all of those “threes.” We use a simpler definition: lots of crying in a baby who we’d hope would cry less.

Babies cry. And that’s the catch, here. They all cry. They don’t have much else they can say. And they’re overwhelmed by all of the changes they’re experiencing, and they haven’t yet learned how to transition from wakefulness to sleep. And some of them don’t like the feeling of rumbly gas in their tummies. And some are scared of their little baby farts. And some of them have parents who are exhausted and strung out and depressed. Honestly, I’m surprised more of them don’t cry all of the time.

But the crying, it can really wear parents down. So all sorts of things have been tried to help soothe crying babies. The latest hip idea (for colic, and almost everything else) is probiotic supplements. These are oral powders that are made of billions of healthy bacteria meant to populate a baby’s gut to help digestion. There’s a lot of research into the “gut biome” and the effect of gut bacteria on the health, specifically relating to digestion and abdominal pain and allergy. Why not toss these at colicky babies, see what helps?

Some studies have shown good promise. Just last month, a study of 589 infants in Italy compared babies given probiotics versus placebo, and found that the babies on a probiotic L reuteri supplement cried for fewer minutes each day (38 versus 71 minutes, on average.) This study looked essentially at the prevention of colic, by giving probiotic supplements to babies whether they had excessive crying or not.

However, the most recent study, a controlled trial of the same probiotic supplement given to colicky babies, showed no effect on any important outcome. The babies, whether given probiotics or not, cried about the same.

Still, there is some good news in common between the studies. The babies, when followed over time, all experienced decreased crying. In other words, colic improved in all groups, whether or not probiotics were given. Also, there we no side effects observed in the probiotic groups. They’re safe, even if they don’t work.

So what does and doesn’t work to help decrease infant crying?

Medicines, universally, don’t seem to work. This includes simethicone (widely available as “Mylicon”, an OTC “gas reliever.”) Studies of medications that reduce acid have also failed to show any effectiveness in improving infant fussiness or crying.

For nursing moms, dietary changes seem to help sometimes—specifically, eliminating dairy consumption. However, this is effective <50% of the time, and you have to weigh a trial of no-dairy-intake versus the effect this has on mom. She needs to be able to eat. Eliminating dairy is difficult (but not impossible)—but eliminating all of the foods possibly implicated in infant crying would be ridiculous. What’s mom supposed to eat, rocks and water? Besides, I don’t like pinning the blame for an upset baby on Mom.

For bottle-feeding families, using a hydrolyzed (hypoallergenic) infant formula has some mixed support from studies. It may be worth a try. What’s unlikely to really help, though, is the endless parade of changing formulas based on manufacturer claims that some are “soothing” or some help in other vague ways.

An insider pro tip I’m not supposed to tell you: As a pediatrician, I can suggest countless alternative formulas for you to try. There are enough alternatives that I can keep changing formulas once a week for at least a few months. By then, baby colic improves. So you’ll think I was smart to finally find the right formula, when in reality I was just changing formula once a week until your baby was going to get better anyway!

So what works best? First, colicky babies need a good, thorough evaluation to make sure that there isn’t a medical problem going on that needs to be addressed. Sometimes that takes more than one visit, and sometimes, if things aren’t going as expected, we have to revisit and re-assess.

But as long as there isn’t a medical issue contributing to the crying, the most important interventions are reassurance, education, and social support. Reassurance that colic does get better, education about safe soothing techniques and signs to look out for, and social support so exhausted parents can get a break once in a while. If parents want to try some safe interventions, that’s fine. But colic isn’t necessarily a medical problem that needs probiotics, diet changes, or medicine. Sometimes, babies just need to cry.

A fussy newborn

Amanda wrote, “My son is 9 weeks old and he cries all the time! He cries throughout the day and night. The Dr. keeps saying that it is colic but I thought that was normally at the same time everyday. This is all day everyday. I have tried gas medicine, Zantac because they said he could have acid reflux and now I have changed his formula that is specifically for colic but there have been no changes. Please help!!! I feel like tests are something should be ran what can you recommend?”

Although some people use the word “colic” to refer to any sort of excessive crying in babies, to most pediatricians colic refers to a very specific pattern of crying. Babies with colic cry at a set interval each day, almost always in the evenings. Many parents will say they can set their clocks by the crying, it’s so regular. The crying peaks at about 4-6 weeks, and goes away by the time the baby is three months old. Although colic can be exhausting, in a way it can be reassuring if your baby only cries excessively during a set time each evening. After all, there is no medical problem that only occurs in the evening. This is sort of crying is not caused by any medical issue, and the main way to treat it is to learn good soothing techniques and provide a way for parents to get some rest and take a break once in a while.

It sounds like your baby, who is fussy all of the time, doesn’t have what I would call “colic.” Excessive fussiness can be caused by many different things, some related to the baby, and some related to the family:

• Reflux, which you mentioned, can lead to pain and heartburn. There are no simple and easy tests for reflux, but if it seems clear from the history that reflux is occurring many physicians will try to treat it.
• Food allergy—either formula intolerance or a problem with something in mom’s breast milk—can cause frequent fussiness at all times of day.
• Temperamental fussiness refers to babies who have a hard time settling down, are anxious, and cry a lot. These babies need extra reassurance, and their parents need extra support.
• Constipation is not common in little babies, but if your child is having firm and painful stools that needs to be addressed.
• Maternal health problems, including post-partum depression, can cause or be caused by excessive baby crying.
• Unusual medical problems in a baby can include urinary tract infections, glaucoma, a broken bone from birth trauma, or really almost anything else. There is no way to “test for everything,” but a careful history and physical exam will reveal almost any sort of problem like these. Rarely, specific directed tests like a urinalysis or an x-ray might be needed.

Your first step is to get yourself some respite care. If you’ve got a very fussy baby, you especially need time to unwind and get some rest. If you don’t have family in town, you may need to rely on a neighbor, close friend, or a hired nursery helper. Do it! No matter what the underlying cause of the fussing, you’ll be able to deal with it better if you have a chance to catch your breath once in a while.

Then, make sure that your pediatrician gets the whole story and a good complete physical exam. Bring notes with a log of the fussiness—when is it? How does it relate to meals and bowel movements? What have you tried that has helped? In my experience the answer to the mystery of a fussy baby is much more likely to be found in clues the parents provide than in any sort of medical tests.

Best of luck, and I hope you get some rest soon!

Reflux and bones

Just last week I published an article on gastroesophageal reflux (often abbreviated “GERD”). I wrote “All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.”

Well, I think I missed the boat on this one.

Sneaky reflux

Allison asked, “My 4 year old was just diagnosed by an ENT (via rigid scope) with reflux and needs Prevacid to control it (Prilosec didn’t help). Otherwise, his voice is quite hoarse. If not for the hoarse voice, we would never have known he had it. Why would a 4 year old have reflux and is it something we should be seeing a GI doctor for?”

Reflux is both one of the most over-diagnosed and one of the most under-diagnosed conditions in pediatrics. That’s right: the same disease that’s diagnosed far too often in some children is at other times very sneaky and easy to overlook.