Parenting Solved

Sleep Feeding - New Problem or Old Sign of Acid Reflux?

Over the past few weeks I’ve had several questions from parents on a problem referred to as sleep feeding.  What is it? Why do babies do it?  What can I do about it?  And (perhaps the most interesting issue) where did this problem come from?  Here’s my take.  And I’ll modify this over time as I learn more. 

What is sleep feeding?  

Quite simply, sleep feeding is a popular term used to describe babies who feed nearly exclusively when asleep.  Better put, these are babies who have such a difficult time feeding when awake that their sleep state appears to relax them to the point that they are more organized and able to feed. Parents are consequently forced to put their baby to sleep in order to help them maintain their intake.  Mention of the problem in our current body of medical literature is scarce, if not absent.  

But while the popular discussion of sleep feeding is new, the problem is not.  I describe the phenomenon of sleep feeding in my 2007 book, Colic Solved – The Essential Guide to Infant Reflux and the Care of Your Crying, Difficult-to-Soothe Baby (see page 46).  And over the past 10 years I’ve evaluated and treated many babies with sleep feeding.

Most babies I have seen with sleep feeding represent variants where some feeding can be completed while awake but only with a great deal of effort.

What causes sleep feeding?  

As someone who has made a living evaluating feeding and digestive disorders in babies, I have found that the vast majority of infants with sleep feeding in my practice suffer with symptoms of acid reflux.  Here’s what happens:

1.     Babies with their recumbent posture, poor gastric emptying, loose lower esophageal sphincters and liquid diets are naturally prone to reflux.  Those with significant reflux sustain inflammation or irritation in the swallowing tube (esophagus).

2.     Painful esophageal inflammation leads to painful feeding marked by frequent pulling from the bottle or nipple.

3.     If not treated, babies continue to struggle to feed and potentially develop an aversion to feeding. 

4.     Parents discover that feeding goes better when sleeping and the pattern is facilitated in order to maintain appropriate milk intake.

Another problem that can predispose to a pattern of sleep feeding in babies is milk protein allergy.  Allergy can create inflammation just like that seen with acid reflux.  And while we always have to consider anatomic problems in any baby with feeding issues, those with anatomic issues in the throat or swallowing tube are unlikely to feed any better when asleep.  In other words, the plumbing won’t change with state of arousal. 

It’s important to look beyond the pattern of feeding while asleep in order to identify what’s behind an infant’s feeding issue.  In other words, the nature and pattern of feeding while awake often offers clues to the presence of reflux esophagitis in a baby.  And the same is true for allergic inflammation in the gut.  Other signs and symptoms as detailed in my book will help identify the baby with subtle signs of reflux or painful feeding. 

In theory, any condition that interferes with smooth, comfortable feeding could lead a parent to help a baby develop sleep feeding.  Consequently acid reflux should not be assumed to be the primary problem.  It needs to be diagnosed based on clinical criteria.

What can parents do with a sleep feeding baby?  

It’s important for parents to understand that sleep feeding appears to be a reactive phenomenon rather than a primary problem or condition.  In other words, feeding during sleep is a pattern that develops out of necessity in a child with an issue that prevents effective feeding while awake. What’s the primary issue?  Consequently our attention needs to be on identifying what’s going on to create such problematic feeding.  This is not an issue that you can resolve on the Internet or through the advice of others in a chat room.  While support is critical, a hands-on assessment by a trained expert is critical. 

Here are a few things to keep in mind when getting help for your baby:

·      Look and treat.  Look for and treat conditions that predispose to painful or difficult feeding.  Acid reflux and allergy need to be firmly excluded.

·      Enlist an expert.  If acid reflux has been firmly excluded, consider an assessment by a pediatric speech pathologist or occupational therapist experienced in infant feeding.  Two things are critical here:  pediatric specialization and infant feeding experience.  You want to find a therapist who spends all of their time with children and has extensive clinical experience in infant feeding disorders.  If you live in a small community, seeking the input of a speech pathologist or OT who dabbles in children may be a waste of time.  Beat a path to the nearest city with pediatric services.  If your pediatrician isn’t immediately comfortable assessing your baby look for consultation with a pediatric gastroenterologist. 

·      Simple feeding difficulty or long standing aversion?  Recognize that when a baby’s primary feeding problem is identified and treated early, normal patterns of eating while awake can often be resumed.  The baby older than 5-6 months of age, however, may potentially have aversive behaviors that persist long after the primary problem has been addressed.  This mandates therapy by a professional experienced in infant feeding therapy.

·      Never force feed.  While tempting, force feeding a baby with an underlying feeding issue is likely to compound the stress, fear and anxiety already associated with the bottle or breast. 

Why are parents talking about sleep feeding?  

This is possibly the most interesting question surrounding the sleep feeding phenomenon.  Why wasn’t anyone talking about this last year, for example.  Is this some sort of new issue?  A modern epidemic perhaps?  Hardly.  As I mentioned, sleep feeding has been around as long as reflux has plagued babies.  The current discussion is just one step in the sequence of recognizing the problem of reflux in babies.

It’s interesting to note that “sleep feeding” or “dream feeding” as a concept has become popularized recently due to social networking – Chat rooms and other forms of social media are allowing mothers with sleep feeding babies to share their experiences and recognize that their baby’s unusual behavior may not be that unusual.  This is a clear example of how e-patients empower themselves and actually get answers. 

Should your pediatrician know about sleep feeding?  

I would have to say that as someone who takes referrals from 200-300 well-trained pediatricians, knowledge about sleep feeding and its relationship to acid reflux disease is not standard.  Remember that acid reflux disease in infancy and childhood is still a relatively new concept.  And considering that this phenomenon hasn’t been reported in the medical literature I wouldn’t expect it to be in the minds of primary care physicians.  Keep in mind, however, that there remain physicians in practice who don’t believe that acid reflux disease is much of a concern in children.  This is one more reason to be informed.

Most babies suffering with sleep feeding will typically demonstrate other signs of reflux or allergy.  But bringing these issues to the forefront during a doctor’s visit is more likely to result in intervention and appropriate treatment.

Help me to help you

If your baby is a sleep feeder I would love to hear from you.  While I can’t offer medical advice, our discussion will help me learn about the patterns of sleep feeding encountered by parents.  Email colic1 at mac dot com.

Bilirubin Neurosis

More and more the Wall Street Journal is becoming a forum for hot child health issues of the day. This morning the front page tells the story of one child who suffered from a rare complication of newborn jaundice called kernicterus. Kernicterus occurs early in life when excessively elevated bilirubin in the blood damages the developing brain. While the exact incidence of kernicterus is unknown, some experts suggest that the incidence may approach 75 cases per year in the United States. Sue Sheridan, the child’s mother, has embarked on a national campaign to prevent kernicterus and this morning’s feature details her mission.

For the uninformed, one might take away from the passionate efforts of Ms. Sheridan that “one simple test” is all it takes to prevent anything bad from happening to a baby. In truth, the appropriate management of jaundice in the newborn must involve the careful consideration of a number of variables including a baby’s age, perinatal history, what they’re feeding, bilirubin level, rate of change, and blood type to name but a few. Jaundice in the newborn always warrants attention but management isn't always straightforward.

While my heart goes out to Ms. Sheridan and her son, the WSJ feature resurrects the timeless debate of when, how far, and at what cost we should take public health measures to identify rare problems. No system for early identification of preventable disease is perfect but a good pediatrician’s judgment likely remains the best means of identifying and treating jaundice in babies.

And by the way, no one rides the main stream media for free. It seems the kernicterus-prevention media campaign has been funded, in part, by none other bilirubin-testing device maker Respironics, Inc.

Mead Johnson Discontinues Low Iron Formula

In a memo to health care providers, Mead Johnson Nutritionals announced yesterday that low iron preparations of Enfamil Lipil are being discontinued. While the company’s formal release doesn’t suggest when we’ll see low iron Enfamil disappear from store shelves, the word on the street seems to be that this will occur sometime in the late spring.

Mead Johnson Nutritionals should be commended for setting a new standard for infant nutrition. For too long the voodoo practice of attributing constipation to normal concentrations of iron in infant formula has driven the market for these inappropriate formulas. Hopefully Ross Nutritionals (makers of Similac) will follow the example set by Mead Johnson and make low iron formulas a thing of the past.

For a more detailed review of why low iron formulas are risky, check out my post, Low Iron Formula – Bad for Babies.

Scent of a Diaper

In Scent of a Woman the blind character played by Al Pacino was able to tell all about a woman based on her scent. It seems moms can do the same thing – sort of.

Australian researchers have found that mothers report the odor of their own baby's soiled diapers as “less disgusting” when compared to the scats of others. The study reported in the journal Evolution and Human Behavior theorizes that this lack of disgust at our own kid’s diapers confers some sort of evolutionary advantage – in other words the fact that we’re not so turned off by our own kids allows us to nurture them and propagate the species.

Interesting side note: At birth the gut is sterile. Over the first several weeks of life the gut is colonized with millions of bacteria. As it turns out, the bacteria that colonize the colon come from mom and dad. So stool characteristics often match that of the family a baby is born into. Perhaps were less turned off to things we’re accustomed to.

This is the stuff that pediatric gastroenterologists find when they surf.

Low-Iron Formula - Bad for Babies

The idea that the iron in infant formula predisposes infants to constipation is perhaps the oldest urban legend kicking around pediatric offices.

The belief that iron in infant formula can create problems for babies may be an extension of the misery experienced by pregnant women when supplemented with iron. When they’ve experienced the effects of iron supplementation, new mothers will often take matters into their own hands. Pediatricians themselves desperate for relief from colicky parents will often gamble with the low-iron card. It’s estimated that low-iron formulas account for 9%-30% of elective infant formula sales in the United States.

So what are the facts? Let’s look at a typical 6 kilogram 3-month-old infant consuming an average of 28 ounces per day formula. An infant fed Enfamil Lipil low-iron receives 4.2 mg of iron per day. The same volume of standard Enfamil Lipil provides 10.1 mg of iron daily. It’s estimated that babies need about 1 mg of iron per kilogram of bodyweight. The baby in our example therefore requires 6 mg of iron daily. The Enfamil low-iron cuts our baby short.

For parents who like to live on the edge there’s Similac low-iron formula. It provides about one third of the iron available in Enfamil’s low-iron formula. In the case of our baby discussed above, Similac low-iron provides a meager 1.3 mg of iron per day.

So what’s the big deal? Iron happens to be very important for brain development. Studies have documented the long-lasting developmental effects of iron deficiency early in life. And what about the association between iron in formula and constipation? There isn’t one. This association was disproved in clinical studies some years back.

What’s important to take home here is the fact that standard infant formula contains appropriate levels of iron, not “extra” iron as is often assumed. Low-iron formula as you see from our example, puts babies at an unacceptably high risk for iron deficiency and should have no place in feeding babies.

It’s been suggested that low-iron formulas should be removed from the market. But so long as misconceptions about formula and constipation exist, there will be demand. And where there’s demand there’s a market.

Nursing Under the Influence

After nine months of disciplined abstinence, you may be ready for that first cool glass of Chablis. And as long as you’re aware of when enough’s enough, the occasional use of alcohol shouldn’t present a problem for you or your baby. As a rule, breast-feeding mothers should avoid nursing within two hours after drinking. Peak alcohol levels are noted in milk around 30-60 minutes after drinking. This may be more prolonged when drinking with food.

What about pumping and dumping? Don’t waste your time. Milk levels match blood levels. In other words, alcohol isn’t stored in breast milk. When the blood level goes down, so goes the alcohol in the milk.

For the hypervigilant, Milkscreen, Inc. of Austin, Texas recently introduced a two-minute test that detects ethanol in breast milk. Breast milk is tested by applying to a test strip that changes color in the presence of alcohol. For the dads who haven’t figured it out, this is like a breathalizer for milk (actually Milkscreen doesn’t quantitate alcohol but simply offers a present or absent verdict).

An interesting spin on this is the fact that lactation consultants are concerned that this could potentially interfere with breast-feeding in by adding unnecessary concern.

Either way, make mine shaken, not stirred.

Grunting Baby Syndrome

It may be the bane of my professional existence but it isn’t found in the major pediatric textbooks. It’s the source of stress and confusion for so many young parents. And too often it’s misunderstood if not mismanaged. It’s grunting baby syndrome.

The baby with grunting baby syndrome will push, squeeze, grunt, change color and carry on only to produce a soft bowel movement. Parents will report that their baby is constipated and seek help. Very often we’re lead down the down the primrose path searching for a solution. But there is no problem. The grunting baby’s problem is one of primitive incoordination. While we all take for granted our understanding of the need for simultaneous relaxation of the pelvic floor and abdominal pressure to poop, not all babies have this figured out. And it’s this lack of coordination that makes us believe that our babies are in trouble.

A common trap for parents and even pediatricians is to stimulate the GBS baby with a thermometer or a cotton swab. When the anus is stimulated, babies exhibit what’s referred to as an “anal wink.” When this happens the bottom relaxes ever so briefly but just enough to allow rectal contents to be eliminated.

The reason this is a trap is that it actually works. And because it works so well we do it again and again. But as the baby becomes accustomed to pooping with stimulation it comes to be that the baby can only poop when stimulated (thus the trap).

The baby with grunting baby syndrome is best left to work out her issues on her own. The simple timing of elimination is something that we all sort out early on and we shouldn’t interfere. As difficult as it may be to watch, the short-term relief of rectal stimulation is never a good long-term solution. Parents of babies with GBS will often look for help after weeks of continuous bottom tweaking and failure of a baby to poop on her own. After a thorough history, physical, and exclusion of other causes I educate the family on GBS and suggest a slow withdrawal of stimulation with the understanding that baby will figure it out.

As far as I can tell, the first formal description of GBS as a clinical entity was made by Dr. Carlo Dilorenzo, Professor of Pediatrics at Ohio State University in the textbook, Pediatric Gastrointestinal Motility Disorders.

Goat's Milk - Not For Kids

Perhaps my greatest professional fantasy is to put the issue of goat’s milk in babies to rest. We’ve entered the 21st century. Our understanding of infant digestive health has advanced to the point where goat’s milk needs to gracefully take its place in history.

So what’s the problem? Although this may be grandma’s solution to “colic”, there are some good reasons why the child under a year shouldn’t drink goat’s milk. Unprocessed goat’s milk is deficient in vitamins B & C, folate and iron. It contains levels of sodium, potassium, and protein which are too high for a baby’s kidneys. Such concentrated levels of minerals can be life-threatening should a baby continue to drink it when sick or dehydrated. Despite its popularity with past generations, you shouldn’t be using goat’s milk or cow’s milk with your baby under 12 months unless you happen to be a goat or a cow.

Our long love affair with goat’s milk is based upon the softness of the curds produced when exposed to acid. Predating the availability of data showing that goats weren’t much different from cows as far as allergy is concerned, our primitive understanding of nutrition was dependent upon what babies brought up in the burp cloth. And to the goat’s credit, their milk does form a softer curd but it has no relevance to what we currently understand about infant irritability.

Stick with breast feeding. If that doesn’t work, use a nutritionally complete formula and save goat and cow’s milk for after 12 months.

Should Parents Weigh Their Babies?

This is the era of parental self-empowerment and it seems more parents are looking to take their baby’s health into their own hands. BloggingBaby raises the question of whether parents should own their own baby scales. With few exceptions infant scales have no place at home. A baby’s gain or loss of weight needs to be considered in the context of their age, history and state of health. And unless a parent is prepared to act on information that they get from the scale, it only creates anxiety. When babies don’t grow it’s usually for a reason that requires professional attention.