Coughing and Choking: When Reflux is More than Just a Little Spit-Up
May 31, 2000
By the time our third child came along, my husband and I were well acquainted with all the myriad of lovely fluids that can leak out of a baby. We soon learned that there are more uses for diapers than covering a baby’s bottom. Through each child’s infancy, we have had cloth diapers stacked on every couch and recliner, in every room of the house, and in each of the cars. I’ve probably bought over 3 dozen cloth diapers and we only used disposables on the bottom half.
The reason for this excess? Spit-up – and LOTS of it! All of our kids have been major "spitters" (though the boys were much worse than the girl) so we got in the habit of having a cloth diaper draped over our shoulder at all times when holding the baby. It got to be part of my wardrobe so much so that I went to the grocery store once – without the baby – and had a cloth diaper on my shoulder (and another one tucked in my back pocket)!
What causes all this spitting up? The technical name for this problem when severe is gastroesophageal reflux or GER. The primary cause of most cases of GER is an immature or underdeveloped sphincter in the lower part of the esophagus. In lay-person’s terms, the little muscle at the bottom of the esophagus doesn’t close well so that the stomach contents can (and do) rise back up in the esophagus and sometimes out of the mouth.
Most cases of GER occur between 1 to 4 months of age and diminish with age so that by 1 or 2 years, almost all children will have outgrown this problem. So what’s the big deal then? Just cover your furniture with sheets for a few months, do lots of extra laundry and wait it out – right? Not necessarily. Beyond the obvious mess and the unpleasant smell of sour milk, we learned of some potential health problems associated with GER.
Complications/Risks Associated with GER:
~ the baby can fail to gain weight and, in severe cases, be diagnosed with "failure to thrive"
~ the baby’s esophagus can become irritated and inflamed from the stomach acid (more likely after 2 months of age)
~ the baby’s esophagus can become scarred and therefore narrower due to repeated acid irritation
~ breathing problems can occur, including coughing, choking, reactive airway disease, and aspiration pneumonia
Symptoms of GER in infants:
~excessive vomiting or regurgitation of breast milk or formula, may be quite forceful
~ wheezing or chronic cough
~ inadequate weight gain or growth
~ excessive crying, especially pain cries
Our first son was a "noisy breather" –he always seemed to be wheezing or congested. In fact, he ended up hospitalized for a day in a mist tent at 3 weeks of age because we were so concerned with his apparent breathing difficulties. Concerns of RSV and asthma were never far from my mind since I’m also an asthma sufferer and RSV was quite common that winter. It turns out that the problem was GER.
Fast forward 3 and 1/2 years later when his younger brother was about 2 weeks of age. We were very alarmed to have him wake repeatedly through the night was violent coughing and choking episodes that literally seemed to leave him breathless! We would immediately pick him up and when the coughing/choking subsided, he would cry as if in pain. Sometimes the choking episodes would happen when he was nursing.
We took him to the doctor but of course he never had one of his episodes there (they never do). In addition, he was gaining weight just fine so the doctor minimized our concerns, probably thinking we were just overreacting. However, this was not our first baby –he was our third – and we had a pretty good idea that what he was experiencing was not normal. We endured the coughing/choking episodes for several more weeks, hoping they would get better but instead finding them getting worse.
Finally I started to keep a log of his coughing/choking episodes in terms of when they occurred and how long they lasted. I was shocked to see that some of them persisted for as long as 5 minutes. The last straw for us was when we finally flicked on the light one night in the middle of one of these episodes and saw that his lips and the area around his mouth and nose were actually turning BLUE!
Another panicky call to the doctor and we were immediately referred to a pulmonary specialist at Children’s Hospital in Seattle. The doctors a Children’s ran a number of tests including a chest x-ray, a barium swallow, and a blood test to rule out Cystic Fibrosis. Thankfully the CF test was negative (though I had a nail-biting week waiting for the results). The chest x-ray, however, showed that his lungs were moderately inflamed. Although he didn’t yet have aspiration pneumonia (due to breathing the regurgitated milk into his lungs), he was definitely at-risk for that. The best guess they had for the cause of his choking was that the stomach acid had irritated his lungs and caused the inflammation.
Treatment for GER:
My son was given a prescription of liquid Zantac (antacid) and after three days of very little change, the coughing and choking episodes virtually disappeared! On the advice of several doctors, we continued the Zantac until about 6 months of age.
In addition to the medication, there were other recommendations given to use to help him with the GER:
~keep him propped/held upright for at least 20 to 30 minutes after each feeding
~ thicken his food slightly with a little rice cereal to make the stomach contents heavier
~ give him smaller, more frequent feedings rather than large feedings that might overfill his stomach
We tried to keep him upright by carrying him around in an infant front carrier. This worked OK during the day but wasn’t very practical for the nighttime. For awhile we tried letting him sleep in his infant car seat. However, we learned that this can actually make the reflux worse because the baby tends to slump down and excess pressure is put on his stomach. We did find some relief by using a reclining bouncy chair at night.
As for thickening his food, I was nursing exclusively so the only way to do that would be for me to pump and give him a bottle. We decided to hold off on that option unless he absolutely needed it and it turns out that he didn’t.
I did try the smaller, more frequent feedings and that helped some, too. Both of my boys were voracious nursers and also had the worst trouble with GER. My daughter, on the other hand, was a sipper. Sip here, sip there. She had some reflux, too, but not nearly as much as the boys. She also didn’t experience any negative side effects of the reflux.
The Most Controversial Recommendation…Sleeping Position
When our first son was having so much trouble with GER, his doctor suggested that he might be better off sleeping in a prone position (on his stomach). We discussed the SIDS research which suggests that putting your baby to sleep on his back reduces the incidence of SIDS. However, cases of GER are sometimes an exception to this rule.
As new parents, we were terrified of SIDS and didn’t want to do anything to increase the chances of this happening. On the other hand, babies with GER who sleep on their backs are much more likely to aspirate and choke on the regurgitated milk. After much discussion and consultation, we settled on a compromise position – side sleeping.
We used a side-sleeper foam support for all of our babies that kept them securely on their sides (for the most part). That way, any regurgitated milk could exit the mouth rather than being inhaled into the lungs. This side-sleeper support worked very well until about 4 to 5 months of age when they started rolling on to their backs and stomachs at night, regardless of the side-sleeper.
The main message I want to get across here is that, yes, sleeping on their backs is the best position for MOST babies. However, for a minority of babies, this can actually be a hazardous position. Parents should have a frank discussion about sleeping position with their child’s doctor if GER is a problem.
As I mentioned earlier, most babies outgrow GER by a 1 year of age, when they tend to be more upright and walking. Our first son continued to spit up (but without complications) until about 11 months. Our youngest son is a few weeks short of 1 year and still spits up occasionally, but the frequency and severity of the reflux has GREATLY diminished. There are a minority of children who continue to have significant problems with GER into the toddler and preschool years and some of them require surgery to correct this problem. Thankfully, it doesn’t look like we will have to deal with that.
Beware of a Possible Alternative Diagnosis: Pyloric Stenosis
If a baby (usually a boy) vomits violently and with increased frequency (almost all feedings) in the first month of life and fails to gain weight, the baby may have pyloric stenosis. This happens when the pyloric muscle between the stomach and the intestine is enlarged and thereby blocks food from getting into the intestine. This usually requires a simple surgical procedure which can correct the problem.
If you have a baby who spits up excessively and has problems either with weight gain, breathing difficulty, or pain-filled cries, a visit to the doctor is in order. It may be a problem that can easily be resolved with positioning or changes in feeding or it may require more extensive treatment such as medication or surgery.
Don’t feel foolish about discussing your concerns with your doctor. Even if they minimize your concerns initially, be persistent if you feel that your babies reflux is becoming a problem (other than messy). Keeping a log will help your doctor get a more objective indicator of the problem. I assumed that my baby’s choking episodes were only 15 seconds long and that they just FELT like minutes to me because of my worry. Once I realized that they actually WERE minutes long and made my baby’s face turn bluish, my doctor was much more helpful in getting the problem evaluated and treated.
For those who would like further information about symptoms, diagnostic procedures, or treatment of GER, the following web sites may be helpful: