Infant Feeding & GI Issues
Among the top 5 topics addressed in lactation consults is the troubling problem of infant digestive issues in the form of colic, reflux, and stool abnormalities. And yes, in case you were wondering, we do want to see pictures of your baby's poop! As Infant Feeding Specialists, lactation consultants often receive training in how to identify and address common causes of upset tummies in infants. Some lactation consultants even pursue specialization in this area, receiving additional education in supporting complex GI issues in collaboration with other healthcare providers.
Signs & Symptoms of GI Discomfort
Mucous in stools (Mucous looks like shiny strings of snot mixed into the poop.)
Blood in stools
6 or more stools per day
Baby has minimal happy, alert times each day
Baby is difficult to soothe even with snuggles or feeds (colic)
About halfway through feeds baby starts to arch and pull
Baby (over 1 month) starts to self-limit feeds to ~2 oz and/or feeds hourly
Spit up frequently upsets baby and seems painful (not to be confused with a baby who is a "happy spitter")
Spit up commonly occurs an hour after feeds and is clear and acidic smelling
Unusually smelly gas in an exclusively breastfed baby
Persistant diaper rash
Cradle cap and eczema
Common Causes & Solutions for GI Discomfort
The Problem: Gut dysbiosis refers to an imbalance of "good" and "bad" bacteria and flora in the gastrointestinal track. More and more studies are elucidating the impact of the microbiome on GI health. Infant studies have found that a lack of beneficial bacteria (often referred to as probiotics) and an over population of harmful bacteria can cause the ph of the bowels to become increasingly high, causing irritation in the lining of the gut (visible when mucous sloughs off), food allergies and other long term health health conditions. Symptoms of gut dysbiosis often include colic, mucous in the stools, diaper rash, eczema, cradle cap, foul smelling stools/gas, and atypical stooling frequency (either very frequent, such as 6+ times per day, or infrequent, such as less than daily).
How it Happens: It is thought that mothers pass on their own microbiome to their infants during pregnancy. This means that whatever the balance of mother's gut flora will become baby's flora. Additionally, the mode of delivery has a major impact on the infant's gut health. This is partly due to exposure to beneficial bacteria during vaginal deliveries, but it is probably impacted even more by the standard practice of giving mothers IV antibiotics if they are Group B positive and/or during their csection which also cross over to baby. Although antibiotics can prevent life threatening infections, they kill off much of the good bacteria that inhabit not only mother and baby's gut flora but also mother's breast microbiome. Studies have found that the beneficial bacteria strain B. Infantis that used to be present in breastmilk generations ago are no longer found in most mother's breast microbiome. This is probably a result of generations of antibiotic use changing the microbiome of humans all around the globe. Studies have also found that supplementing these same beneficial probiotics to formula-fed babies is less effective as the bacteria need breastmilk to survive. Unfortunately, the lack of these beneficial probiotics make it harder for mother and baby to digest and increase gastrointestinal irritation.
Solutions: Studies have found that diets rich in diverse fruits and vegetables for adults or exclusive breastmilk for babies help feed a healthy microbiome. Sugar, on the other hand, feeds predatory bacteria. Fermented foods such as raw sauerkraut and kombucha are replete with probiotics. Mothers can try to incorporate these foods into her diet. Over the counter probiotic supplements are also being increasingly used to help improve gut health. Studies have found that when mothers take a high dose of probiotics contain the strains L. Gasseri and L. Salivarius their risk of mastitis decreases significantly (especially if they had antibiotic exposure in the past year) and some of these helpful probiotics transfer to baby while breastfeeding. For infants, the probiotic with the most clinical success in studies is L. Infantis produced by the company Evivo. We have seen dramatic improvements for babies with GI discomfort with a month of Evivo. Within days bowel movements patterns normalize (1-4 per day), diaper rash resolves and fussiness improves. Issues like mucous or blood in the stools and cradle cap have often been completely reversed, while baby's tolerance of difficult-to-digest foods like dairy have improved. Its amazing how much good bacteria support our immune system and gut health!
Gastroesophageal Acid Reflux (GERD)
The Problem: Reflux is acidic spit-up that burns baby's throat as it comes up and causes heartburn type pain for baby. The heartburn often sets in about halfway through a feed and may cause baby to start to arch and fuss during the feed. About an hour after the feed acidic reflux may occur, which can be swallowed back down or come out as clear looking spit-up, causing baby to cry out in pain as it comes up. In contrast, spit-up is considered normal in young babies if it occurs right after feeding, looks milky, and doesn't upset baby. The constant pain during and after feeds may cause baby to self-limit their breastmilk/formula intake to ~2-2.5oz per feed. Some babies with GERD will feed very frequently feeding as they try to soothe their throat with milk or may start to refuse feeds if they develop a negative association with painful feeds.
How It Happens: GERD can have many causes, but by far the most common cause we see is reflux that is the result of suck dysfunction associated with tongue-tie. Babies with tongue-tie almost universally swallow more air (termed "aerophagia") when they eat, and this build up of air can cause their stomach contents to be under pressure. Additionally, tongue-tie limits the tongue's contact with the palate which is a major stimulation of saliva and the digestive enzymes that accompany it, potentially reducing baby's ability to comfortably break down foods. Additional contributions to GERD could include low or high muscle tone, gut dysbiosis and food allergies.
Solutions: First, suck dysfunction needs to be ruled out or addressed by an infant feeding specialist highly trained in oral motor evaluation (all of our lactation consultants have received extra training in this area). Addressing aerophagia is absolutely key to relieving baby's distress. Next, having mother avoid foods like dairy and soy during the healing process can improve baby's comfort since these foods contain difficult to digest proteins. Both mother and baby can take probiotics as described in the gut dysbiosis section. Encourage baby to take frequent, small feeds instead of large, spread-out feeds as this produces less GI pressure. Use feeding positions that keep baby's head elevated higher than their bottom, such as the reclined breastfeeding position or paced bottlefeeding position pictured, which also give baby more control over their suck/swallow/breathe patterns. If baby is not gaining weight appropriately due to feeding aversions, GERD medications should be considered in consultation with baby's doctor. These medications have long term risks including higher risk of developing food allergies and broken bones in childhood, so should be reserved for infants with severe GERD. A homeopathic option for mild-moderate GERD is Hyland's Acid Neutralizer. Finally, bodywork to help baby with muscle tone and tension can make a big difference in addressing underlying reasons why a baby is prone to GERD. This might include an hour or more a day of tummy time, massage/CST, and chiropractic care while avoiding excess time spent in "containers" such as bouncy seats, car seats, rock n plays, etc.
Food Allergies & Intolerances
The Problem: A surprisingly high number of babies have difficulty digesting certain food proteins and/or have allergic reactions to foods that the breastfeeding mother ingests and/or in the infant formula. This can cause stomach pain, atypical stools (mucous, blood, or green), eczema and reflux. Dairy is the culprit in about 30% of colicky babies (primarily the cow's milk proteins casein and whey), with the next most common food offenders being soy, egg, nuts, wheat, fish, and corn.
How It Happens: Family history seems to be a big risk factor for infant food intolerances and allergies, especially if mother has a GI condition such as IBS, Crohn's or Colitis. If mother has poor digestion, more of the food proteins will transfer into her breastmilk without first being thoroughly broken down by her digestive system. This is sometimes referred to as "leaky gut." Its not known why some people develop food allergies (vs intolerance), but studies have found food allergies are more likely to occur if mother did not consume the food during pregnancy. Infant exposure to a wide variety of foods during pregnancy, lactation and solid foods (between 6-12 months) helps minimize the risk of developing food allergies.
Solutions: Supporting mother's digestion and both mother and baby's gut microbiome are key to relieving food intolerances. This often includes digestive enzymes that mothers can take with meals and probiotics for both mother and baby. To pinpoint which food is causing baby's symptoms, we often recommend mother eliminating one food at a time for two weeks, beginning with dairy. When sourcing dairy substitutes, its best to choose substitutes with low allergen risk such as oat milk (not soy or almond milk). If baby is formula-fed, a hypoallergenic infant formula should be trialed. However, ideally exclusive breastmilk will best support baby's overall health and well being. Foods that baby reacts to should be eliminated until baby is symptom-free for several weeks and then carefully reintroduced while monitoring for reactions. It takes time for an infant's gut to heal, but with the right environment in place there is hope that baby will eventually tolerate those foods.
The Problem: One of the simplest and yet most misunderstood causes of infant digestive distress is an overload of lactose in baby's tummy. Lactose is the main carbohydrate found in breastmilk and is an important ingredient for a baby's growth and development. Although babies are pros at digesting lactose (they make plenty of the enzyme lactase until they are about 5 years old), even their tummies are sometimes no match for the speed of lactose moving through their systems if not paired with slower digesting milkfats. Lactose overload can result in gas and green, frothy stools.
How It Happens: In years past lactose overload was referred to as "foremilk/hindmilk imbalance," back when it was thought that the breast produced two seperate milks, one rich in lactose ("foremilk") and one rich fat ("hindmilk"). Mothers were given complicated feeding schedules to help ensure babies got the right balance of foremilk and hindmilk. In recent years we have learned that the breast only produces one consistent type of milk with the perfect balance of fat and lactose. However, if there are several hours in between feeds the milk has time to separate with the milkfat floating to the top of breast within the glands. If mother also happens to have oversupply, baby might get full drinking from the "bottom" of the breast without room in her tummy to get to the milkfat at the end of the feed that helps slow digestion. The rush of lactose without milkfat paired with it can cause irritation in the gut and quickly speed through the tract coming out with green bile present.
Solutions: If lactose overload is suspected due to oversupply and green, frothy diapers, there is a very simple solution. Before latching, mothers can massage and jiggle their breasts to help mix the milkfat back into the milk. This is referred to as "The Milkshake Technique." Just like shaking a bottle of separated milk, this will quickly mix the fat that floated to the top of the breast into the rest of the milk. If done consistently every time there is a few hours between feeds, this should be an instant fix. Encouraging frequent feeds (so the milk has less time to separate) will also reduce this problem. Additionally, mothers can consider strategies to regulate oversupply. We do not recommend block feeding (purposefully limiting feeds to one breast) as we find it it can have a variety of unintended consequences.