by Richard Pass, RN
Director, Save A Little Life, Inc.
Richard Pass, RN, BS, founded “Save a Little Life” in 1999. He has been a Registered Nurse & Health Educator for over 30 years. He is on staff at Cedars-Sinai Medical Center in Los Angeles and is currently a part-time clinical instructor of nursing at California State University, Northridge. The goal for Save a Little Life is to provide a simpler, more “user friendly” CPR course. Savealittlelife.com
When doing my pediatric CPR and family emergency workshop I often hear parents concern over episodes where the infant seems to stop breathing, causing tremendous fear for that family. In some instances a 9-1-1 call is made, particularly when the baby “turns blue” (a cardinal sign of low oxygen). These episodes are frequently associated with feeding which increases the perception that a choking event is underway.
Because of these very real fears many parents visit their pediatrician’s office and want answers. According to a recently published article in the Journal Pediatrics, there has been an alarming increase in the diagnosis of “infant reflux.” Among other things, this has been the cause of a huge increase in treatment, principally with the prescribing of acid suppressing medications (Pepcid, Zantac, etc.) for these infants.
What Is Reflux?
Taber’s medical dictionary defines reflux as “a return or backward flow.” Consequently, the terms (reflux and regurgitation) are often used interchangeably. Various studies reveal that a major percentage of the infant population in the U.S. (40-70%) has some form of reflux event. In many cases these events are noted when a baby “spits up” during feeding. There are, however, numerous occasions when I have heard parents tell me that some form of regurgitation can happen during non feeding times.
The rapidly growing infant usually ingests volumes of food (breast milk/formula, etc.) that on a per kilogram basis are much greater than larger children or adults. Because of this relative high volume and a relatively shorter esophagus (stomach tube) a “spillover effect” can occur. Many pediatricians believe this to be “physiologic reflux” as opposed to “reflux disease.”
Episodes of this spillover can occur infrequently or multiple times a day. This puts many parents and care providers on constant alert, often causing significant anxiety, including fear of feeding the infant. Several medical studies suggest that the situation is self-resolving in approximately 95% of infants by 12-15 months of age.
Reflux and the Incidence of Apnea
Without question, the issue of effective breathing during these episodes is of primary concern to the parents I speak with. So, what is the relationship here? In depth studies looking at the relationship of regurgitation and apnea (cessation of breathing) consider the physiologic factors. Basically, “apnea is linked to a reflex in the larynx (near or around the air passages) cause respiratory pauses, airway closure, and swallowing immediately after regurgitation to the upper airway.” The consequences of these episodes are usually minimal to non-existent. Yet, as mentioned earlier, some infants have prolonged apnea, turn blue and on some occasions begin to lose consciousness. These are clearly the most unusual but cause the most panic in the parent or care provider.
Getting the Right Diagnosis
It is far too simple to assume that if an infant has episodes of reflux/regurgitation, that they in fact have GERD. There are specific diagnostic markers that your physician will look for before making this diagnosis. In the meantime, there has been a skyrocketing in the use of the aforementioned medications to treat the symptoms of reflux. One belief is that parents are so affected by the promotion of medications (usually seen on T.V. for the adult population) for this disorder that they demand a prescription and, in fact, often feel that the baby is under-treated if they leave the office without one. It turns out that the F.D.A. has not approved the use of these medications, specifically for the infant population.
In the meantime, what can parents do to assure that their baby is safe? The most common recommendations tend to include:
• Propping the infant at a somewhat higher angle while feeding
• Increase the time between feeding and going down for nap/sleep
• Place some risers at the head of the infant’s crib (several inches at least)
• Keep a “spitting up” or reflux log that you can refer to when speaking with your pediatrician
In those very rare instances when breathing stops and the infant turns bluish in color (either face, lips, etc.) you should be prepared to stimulate the infant by using a modified “airway obstruction” position, and use some patting to their back when they are turned in a head down position. This stimulation is most likely what will get a response, even though this is not a true airway obstruction event.
Finally, be prepared for the most unusual of events —where a baby has prolonged loss of breathing. This may require the initiation of CPR in rare cases. Haven’t taken a pediatric CPR course recently? Call Save a Little Life and sign up for one today.
Save a Little Life, inc.