Positioning a Preemie baby with acid reflux (GERD)
by Dr. Bryan Vartabedian
Thursday, February 07, 2008
While handling babies with acid reflux can be tricky, handling premature
babies with acid reflux can be trickier. That may be changing, however.
Two studies published last month in the Journal of Pediatrics have found
that post-feed gastroesophageal reflux (GER) in preemies is increased when
babies are placed in the right side down or supine positions. Both studies
looked at acid reflux in 35-36 week premature babies using state-of-the- art
impedance monitoring (unlike pH probe monitors which record acidic activity
in the esophagus, impedance monitoring allows doctors to look at non-acidic
as well as acidic reflux).
While the idea that refluxing babies do better on their bellies isn't
necessarily new information, right versus left-sided positioning has been
more often contested among gastroenterologists . These two studies offer more
support for belly sleeping and add to the debate of side sleeping. The fact
that these studies were done in preemies is perhaps more newsworthy.
For parents with refluxing preemies the idea of belly sleeping creates a
dilemma since we've been back sleeping our babies for over a decade. I face
this belly-versus- back issue on a regular basis in my clinic. While no
self-respecting baby doctor is able to flatly recommend belly positioning,
the parents of the sickest babies soon find out that this is the only way
that they can survive with their baby. The misery and choking of the sick
refluxer often forces the issue. With that said, look to your doctor for
advice since each and every little creature is different.
Can we apply these findings to full-term babies? Probably. While the
intestinal motility pattern of a 35 week preemie is different that that of a
4-week-old full-term baby, their anatomy isn't much different. I suspect
that plumbing may have been more important than squeezing in these studies.
Add positioning to your list of simple measures for making your reflux baby
happier and healthier.
For more information on how to hold a baby with GERD, see: (which I've added
below)
New Information on Positioning a Baby with Reflux
by Jan Gambino
Parents of infants with acid reflux disease always want to know the best
positioning for eating, sleep and play. Positioning is a simple, low cost
treatment attractive to parents when faced with the other treatment options
such as medication and expensive formula.
But it’s not always so simple. Keep in mind that positioning may be the only
treatment needed for the baby with Gastroesophageal Reflux (GER) who spits
up often but is otherwise healthy. A baby with Gastroesophageal Reflux
Disease (GERD) may greatly benefit from positioning to promote digestion and
decrease reflux events but may also require other treatments such as
medication and a special diet. So, be sure to ask your doctor for advice
before trying any new treatment, including positioning.
Two studies provide new insights
The Journal of Pediatrics just published new research on the effect of
positioning a baby after mealtime and the number of reflux events. This type
of research is important because parents and doctors have a hunch that
positioning is important but, up to now, theres been little research to
confirm the theory. The new research may guide doctors in developing new
treatment approaches and decrease the need for medication.
Study 1: In one study, the researchers measured the acid levels in premature
infants using an impedance test (a test to detect acid and non acid reflux)
just after a meal and then an hour later. They found that the infants
stomachs emptied faster when they were placed on their right side. Then when
the baby was moved to the left side one hour after a meal, reflux episodes
decreased rapidly.
In this study, the researcher concluded that laying babies on the right side
just after a meal and then moving them to left side one hour later decreased
reflux.
Study 2: In the second study, the researchers studied premature infants with
a diagnosis of reflux using impedance testing to measure acid and non-acid
reflux events. Researchers observed the infants in four positions: back,
stomach, left side and right side. They noted reflux episodes just after a
meal and later after the meal had been digested. They found that stomach and
left side positioning decreased reflux events. Further, left side
positioning provided the lowest acid exposure after a meal and stomach
positioning provided the lowest acid exposure later after a meal had been
digested.
In this study, the researchers concluded that placing a baby with reflux on
the stomach or left side after a meal was useful to decrease acid events.
Finding what works for your baby
Confused? You’re not alone. As a parent of a baby with reflux, it is
confusing to sort out all of the treatment recommendations and advice from
friends and family about the best way to hold your baby. You have probably
used trial and error to find a way to hold your baby to decrease fussing and
crying. It may not work each time and you might have a few different
positions that have the best chance for success.
My first daughter was born in the era when stomach sleeping was recommended.
I quickly found out that she preferred to sleep on her side or back. She
settled faster and slept longer. Of course I was terrified that she would
choke in her sleep and worried about her! My refluxer, however, were born
after the Back to Sleep Campaign and I was instructed to place her in the
new, safe back positioning for sleep. After my little refluxer was sound
asleep on my shoulder, I dutifully placed her in the crib on her back. The
second her little back touched the Winnie the Pooh sheets, she would be
awake and screaming. I would repeat this sequence over and over, until I
gave up and spent the night holding her over my shoulder while propped up on
pillows in bed. As I sat in the dark, I thought, There must be a better way
Right now the best advice seems to be this:
· Always place a baby on her back to sleep to reduce the risk of Sudden
Infant Death Syndrome (SIDS).
· Try elevating the baby to a more upright position to avoid reflux.
· Talk to your doctor about your baby’s specific condition to determine the
best treatment actions.
Parents’ personal experiences
Parents often tell me that placing their baby over the shoulder after a meal
is best for decreasing vomiting and increasing comfort. Unfortunately, some
parents end up holding their baby over the shoulder 24/7 if the baby is in a
high level of distress.
It may be tempting to place the baby on her stomach in the crib after she
had settled on your shoulder so you can both get some rest. There is the
very strong evidence that placing a baby on her back for sleep greatly
decreases the risk of sudden infant death syndrome so regardless of the
severity of the reflux, parents are still instructed to place the baby on
her back for sleeping at all times.
As researchers learn more about the pattern of digestion before, during and
after meals, and the effect of positioning, treatments can be targeted to
the actual causes of reflux and ensure that the treatment is successful.
Meanwhile, parents need to follow the advice of the doctor to develop a
treatment plan that is designed to address the needs of each child. In the
future, perhaps there will be new positioning recommendations based on
larger studies to confirm the results of these studies. In addition, there
is some evidence that elevating the baby to a more upright position reduces
reflux. More research is needed to study all sleep positioning.
As I was reading the studies this week and reflecting on the sleep patterns of my children, I had a
wild theory. What if the Back to Sleep recommendation decreased deaths from Sudden Infant
Death Syndrome but increased infant reflux? I guess research will reveal answers to these
questions in the future.