Friday Favorites: Treating Reflux in Babies with Diet

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

There has been a longstanding problem among zookeepers of the gorilla. Latin name: Gorilla, gorilla gorilla.

The problem is that they were throwing up all the time. We’ve never seen wild gorillas barfing, but it had “unfortunately been accepted as” routine by many zoos. What were they feeding them? Well, you know they’re big strong animals, so they made sure to feed them lots of protein; ya know, cottage cheese, meat, eggs, milk—until a zoo in Germany got this radical idea to try giving them their natural diet. And? “The change…following the alterations to the diet was astonishing.” I mean before, the poor silverback was “regurgitating and vomiting during most of the day.” But by the third day eating what they were supposed to eat, he and the rest were all miraculously cured. Even just “removing milk from captive gorilla diets” led to significant improvements. Cow’s “[m]ilk was historically considered an essential item in the captive gorilla diet,” but they showed that “removal of milk from the captive gorilla diet may reduce [such] undesirable behaviors…and may be a step toward better approximating [their] natural diet.” I mean, giving an animal milk after weaning? Giving an adult animal milk? Milk is for babies! And then giving milk from a bovine to a primate? What were these crazy zookeepers thinking? Doesn’t make any sense!

Reminds me of this landmark study. Eighty-one children presenting with reflux, gastroesophageal reflux disease, so they were given drugs, and two-thirds got better, but 27 kids still did not. So, they tried eliminating cow’s milk from their diets, and within one month, all 27 were cured. 

“Symptoms of acid regurgitation, heartburn, or both, occur at least once a week in 10–20% of adults [in] the western world”—and, in about up to 25 percent of all infants. Now, it’s normal for babies to spit up occasionally—that’s not what we’re talking about. It can actually get quite serious. Up to a quarter of infants “present with regurgitation severe enough for parents to seek medical help,” and it may just be that they’re sensitive to cow’s milk. “The symptoms of [cow’s milk protein allergy] overlap…or may coexist or complicate GERD” or reflux. Even if there’s no formal dairy allergy per se, there appears to be some kind of cow’s milk “hypersensitivity” among many infants and children with severe reflux.

There are all sorts of invasive tests you can do, like stick pH probes down the poor baby’s throat, but probably “the most practical test in routine [pediatric] practice” is just a trial of a cow’s milk protein-elimination diet for two to four weeks in infants with reflux.

The gold standard is what’s called an “elimination and re-challenge protocol,” where you see “full resolution of symptoms via a strict elimination, followed by recurrence [of the symptoms] on reintroduction of cow’s milk protein.” And, when you do that, take 200 or so infants diagnosed with reflux and then not only put them on a cow’s milk-free diet, but then do the challenge tests. Eighty-five of the 204 infants with reflux were actually suffering from a cow’s milk allergy, or at least hypersensitivity or something.

What we think is happening is that our immune system attacks the bovine proteins as understandably foreign, triggering an inflammatory response, which like irritates the nerves lining your digestive tract, and that results in abnormalities in the rhythmic contractions of the stomach, triggering the regurgitation. And, we’re not just talking about formula-fed infants. Cow’s milk protein allergy “can occur in exclusively breastfed infants, as intact cow’s milk proteins can be secreted in breast milk.” If the mom drinks milk, or eats eggs, it can get into her baby. “Cow’s milk protein and other [foreign] proteins [can] pass into human breast milk. So: “Breast-fed infants with regurgitation and vomiting may therefore benefit from a trial of withdrawal of cow’s milk and eggs from the maternal diet.”

And indeed, that is now the consensus recommendation of both the North American and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Anytime you see reflux, let’s first try “a therapeutic trial” of either a cow’s milk protein–free formula, or, “for infants who are breastfed, a maternal strict [cow’s milk protein] elimination diet.” And so, then we can potentially treat the cause “without using unnecessary medications,” and certainly before you start considering performing any anti-reflux surgery on the poor kid.

Please consider volunteering to help out on the site.

• Ruempler U. The Cologne Zoo diet for Lowland gorillas Gorilla gorilla gorillato eliminate regurgitation and reingestion. International Zoo Yearbook. 1992;31(1):225-229.
• Lukas KE, Hamor G, Bloomsmith MA, Horton CL, Maple TL. Removing milk from captive gorilla diets: The impact on regurgitation and reingestion (R/R) and other behaviors. Zoo Biology. 1999;18(6):515-528. doi:10.1002/(sici)1098-2361(1999)18:6<515::aid-zoo6>3.0.co;2-t.
• Salvatore S, Vandenplas Y. Gastroesophageal reflux and cow milk allergy: is there a link?. Pediatrics. 2002;110(5):972-984.
• Iacono G, Carroccio A, Cavataio F, et al. Gastroesophageal reflux and cow's milk allergy in infants: a prospective study. J Allergy Clin Immunol. 1996;97(3):822-827.
• Vandenplas Y, Hauser B. An updated review on gastro-esophageal reflux in pediatrics. Expert Rev Gastroenterol Hepatol. 2015;9(12):1511-1521.
• Ferreira CT, Carvalho Ed, Sdepanian VL, Morais MB, Vieira MC, Silva LR. Gastroesophageal reflux disease: exaggerations, evidence and clinical practice. J Pediatr (Rio J). 2014;90(2):105-118.
• Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49(4):498-547.
• Allen K, Ho SS. Gastro-oesophageal reflux in children--what's the worry?. Aust Fam Physician. 2012;41(5):268-272.
• Farahmand F, Najafi M, Ataee P, Modarresi V, Shahraki T, Rezaei N. Cow's Milk Allergy among Children with Gastroesophageal Reflux Disease. Gut Liver. 2011;5(3):298-301.

Image credit: noranorakatonamona via Adobe Stock photos. Image has been modified.

Motion graphics by Avocado Video