Reflux, Allergies & Sleep: An interview with Pediatrician Tina Feeley

Reflux, Allergies & Sleep: An interview with Pediatrician Tina Feeley

Amanda: Hi. Today we're talking to Dr. Tina Feeley. She is a board-certified Pediatrician through the American Board of Pediatrics. Currently, she is practising as a general Pediatrician in Virginia.

She did her undergraduate degree at Boston College, and they went on to Dartmouth, where she received a master's in public health from the Dartmouth Institute for Health Policy and Clinical Practice. She then went on to medical school at Rutgers University at the Robert Wood Johnson Medical School, where she graduated with honors. She completed her pediatrics residency at the Children's Hospital of the King's Daughters in Norfolk in Virginia, and she lives in Virginia with her husband and two daughters.

Today's topic that we're talking to Dr. Tina Feeley about is reflux. Welcome, Tina. First of all, can you just walk us through your motherhood journey? Was it easy for you or was it difficult or... can you tell us a little bit about that?

Tina:  So, in terms of my motherhood journey, I was a Pediatrician and I graduated residency prior to becoming a mom. And my husband and I are actually both Pediatricians, so I think we both knew what we were getting ourselves into, in terms of baby's waking up every two hours to feed, and that our life was going to change a lot. But I think that even being two people who, arguably, more qualified to have children than you can imagine, I don't think anything truly prepares you to become a mom, or a dad in that case, for him. Especially... the sleep thing was honestly the biggest struggle because our daughter did not sleep for more than 45 minutes at a time for about two months. It really got to be draining and feeling like, "am I really going to be able to do this?" Even as a Pediatrician, but the joys of motherhood have just been something that I could have never imagined, being this happy or having so many highs at the same time. But it definitely was not as easy as I thought it would be, even being someone who knew that it was going to be kind of difficult to begin with, too.

Amanda: Yeah, yeah, I agree. I don't think anything can really prepare you for what you're in for after the birth. I think, even as you said, you'd seen all of the things that can happen, but still, nothing quite prepares you yourself.

Tina: Yeah. You know, in theory, what waking up every two hours is going to be like, or that someone, another human... you are solely responsible for all of their care, but I don't think you truly understand what it is until you're living it, so it's been a great experience overall. Just not the initial shock.

Amanda: Yeah, that's right. So, being a Pediatrician, what are the most commonly dealt with issues that you come across?

Tina: So, I would say the biggest questions that parents have when they come in to see me, one is definitely involving sleep. How much sleep should their baby be sleeping, strategies to get them to sleep, and things like that. The other one is definitely feeding. So, in terms of what to feed, how much to feed, how much the baby should be taking, or a child should be eating. And then, also about growth and development. So, what should the child be doing at that age versus what they are doing, is what they're doing normal, is it not normal? So, I think those are probably the three major things. And then obviously, I see the everyday colds and asthma and things like that. But, in terms of the questions that parents have, it's usually regarding sleep, feeding, and growth and development.

Amanda: Right, right. So, talking about reflux now, we know some babies can be, maybe, misdiagnosed or diagnosed with reflux, when potentially they're actually overtired or maybe undertired. Can you talk me through that and do you see this yourself?

Tina: I think so. I don't know, necessarily, that it's that they're overtired or undertired, but I think the main things with children with reflux, and babies who are overtired and babies who are undertired, is they all are kind of a little fussy. And reflux is one of those things that almost all babies do, especially in the first three months of life, just the nature of how the baby's anatomy is. So, the oesophagus, which brings the food from your mouth to your stomach and your stomach has, in adults, a sphincter, which is like a valve, which keeps fluid in your stomach, it keeps it from coming back up. But in babies, it's not really developed until later. So, almost all babies, it's just kind of an open tube between the mouth and their stomach, and they'll reflux. And so, a lot of fussy babies, because parents will notice that they're refluxing or notice that they're spitting up a lot, they kind of associate that with the reflux, even though it might not actually be the reflux, it might be that they are fussy for another reason. It might be that they're overtired, it might be that they're undertired, but because this is something that's happening all day, every day for the majority of babies, I think that's something that people often attribute to a fussy child.

Amanda: I guess it's also whether the reflux itself is actually causing, after the spitting up, is actually causing pain or if they're just spitting up and then they're going on about their life as a happy little baby, as well.

Tina: Exactly, so I think sometimes, parents will attribute what they're seeing, and what they're seeing is the act of them spitting up, even though that's actually not what's causing them to be fussy at all. It could be something else that's going on, such as being overtired, undertired, or something else.

Amanda: Exactly, that's really good. So, what are the key symptoms that people, or parents, should be looking out for with reflux, and when should they seek some professional help, or when should they come and see you?

Tina: Yeah, I mean, I would say, in general, if you ever have a concern about your baby, go to your doctor. So, there's never anything that I would say is not worthy to come to me and ask a question. We get all sorts of questions, and even if I tell you that everything is normal, that's okay. That's worth my time. But, in terms of reflux that would be causing an issue for the baby, so it is causing pain... So, some of the signs of that, it's an emergency if the reflux or the spit up is ever red or green. So, that means that there's either blood in it or bile in it, and that is always an emergency, and you should go straight to the emergency room. If the spit up is projectile after every single feed, so what I mean by that is it's literally shooting across the room with every single feed, then that's a concern that you should definitely go straight to the emergency room for, too, because you don't want your baby to get dehydrated or see if other things are going on.

And then, in terms of the spit up that's not necessarily an emergency, but you should talk to your Pediatrician or your doctor about, are things where you're noticing that your baby isn't feeding well or they're refusing their bottles or they're spitting up and seeming like they're in pain while they spit up at the same time. That would all be something that is a sign that it's more than just spit up.

Amanda: Yeah, definitely. Myself, I was a projectile baby, and I used to apparently hit the other side of the room. 

Tina: Oh God. Yeah, it can be disconcerting, especially for parents. A lot of times, parents will come in and say, "Oh my goodness, but it's coming out of their nose." And I'd say, "Well, it's actually normal. Everything is connected back there," so if it's coming out of their nose, that's not necessarily abnormal. But if it's forceful after every feed, it is. One thing that babies do, especially when they're in pain, is not only will they cry when they spit up, but they'll arch their back, and they'll sometimes get really stiff, and it's really concerning to see because sometimes it'll even cause them to kind of take a pause breathing and things like that. So, if you've ever seen that, then that's definitely a reason to go to your doctor and to seek help. But if your baby is spitting up and what we call reflux, but it's not reflux disease... but if they're just spitting up and you didn't even notice, they didn't cry, you just happen to look in their bassinet and they have some spit up on their sheet or something like that, but they're just living their life and totally happy and they're feeding well and gaining weight and growing, then it's not something, generally, you need to worry about. But again, always talk to your Doctor, your Pediatrician, if you're ever concerned about anything your baby's doing.

Amanda: Yeah, definitely. So, how does reflux affect a baby's sleep?

Tina: So, reflux can affect a baby's sleep in that, generally, it's going to be worse when the baby's laying flat on their back. So, with that said, we always want a baby to be flat on their back on a separate firm sleep surface for safe sleep. But when a baby has reflux, that's always going to be a position where they can make the actual spit up worse, in that it's coming up from the stomach to the mouth because they're lying flat on their back and they're not having gravity help keep it in their stomach. So, one thing that we always recommend that parents do is, after they feed their baby, if they do have a baby with reflux and the spit up is hurting them, to make sure the burp their baby in between their feeds.

So, if they're nursing, between each breast, to burp their baby, or if they're bottle feeding, after every ounce or two, to burp them, and then to actually sit them up and hold them up for about 30 minutes after the feed. And that can oftentimes help, so that way, by the time you put the baby back on their back, on their firm, flat sleep surface for their safe sleep, but at least they've kind of digested some of the milk a little more, so it won't be coming right back up. But we still always emphasize safe sleep so that they're sleeping on their back, on a separate sleep surface because we don't want them sleeping inclined or in an unsafe position for the reflex itself.

Amanda: Right. And so, if a baby is diagnosed with reflux that needs to be medicated, how does the medication work and what should parents expect to see as a result?

Tina: So, in terms of the medicines, there's two different types of medicine, but they both act against the acid part of the reflux, so it's not going to stop the reflux from happening because reflux is really just spit up, and you still don't have that valve between the oesophagus and the stomach to keep the food in the stomach. So, the food's still going to come up, the milk's still going to come up and go down and come up and go down, but what the medicines do is, they prevent the acid so that it makes it less painful. So, ideally, they turn from being a fussy infant with reflux to an infant with reflux that it really doesn't bother them, is the goal. But the goal is not that it will actually stop the reflux itself or the spit up. The goal is that it will actually just stop the pain associated with it, so that they won't be waking up and things like that.

In terms of sleep, I know a lot of parents, it can be concerning when their baby spits up because they say, "Well, they're going to choke on it because they're lying on their back and then they spit up." But actually, it is safer for them to be on their back than on their stomach because your food pipe is behind your windpipe, so your oesophagus is behind your trachea. So actually, when you're laying on the back, the more likely they'll just re-swallow it than if they're laying on their tummies, so that's another thing for parents to keep in mind, that it is actually still safer for them to be on their back, even though they're still going to be kind of spitting up throughout the night and everything.

Amanda: Excellent. Well, thank you so much, it's been really informative, and I hope that everyone's learned something about reflux and head to your doctor or GP or your Pediatrician if you have any questions. Thank you so much, Tina.

Tina: Absolutely. Thanks for having me.

Allergies & Intolerances 

Amanda: Today's topic that we're talking to Dr. Tina Feeley about is allergies and intolerances. So can you tell us what the difference is between an allergy and an intolerance?

Tina: Absolutely. It's a great question. So an allergy is something that is going to cause issues in your body that can be potentially life-threatening but also harmful to your body in general, especially over a long period of time. So there are different types of allergies. There are the food allergies you think of where you need your EpiPen, where it causes the hives, and the wheezing, and the vomiting, diarrhoea, and just a lot of almost instant reaction within a half-hour to an hour of eating that food.

And then there's other allergies like celiac disease,

remote protein allergy that can cause your body to have bloody poop and to not being able to digest food well and things like that. So there are things that cause you to have ultimate harm to yourself.

An intolerance is something that makes you feel kind of lousy, but it doesn't actually cause any damaging effects to you in general, besides the fact that you feel kind of lousy, but it won't cause ultimate harm, or potentially kill you, or things like that.

So those are kind of the major differences just from how we separate them in terms of how we think and then the ultimate difference comes down to biology, which we don't need to get into. But it comes down to the actual reactions that are happening within your body when you're exposed to the foods as well.

Amanda: Right. And so what are the most common allergies and intolerances that you see in children and babies?

Tina: Yeah, so it really depends on the age. So by and large, in the newborn period until a baby needs solid foods, the number one allergy is usually a milk protein allergy.

So a milk protein allergy is something that the baby actually has an allergy to the milk, but it's not an allergy that you think of with getting hives and trouble breathing and things like that. It actually affects their gut. And then the major symptom with it that we use to diagnosis is having bloody stool. So having bloody poop, but also they are generally vomiting, refusing bottles, very fussy, uncomfortable. The major hallmark is the bloody poop.

With that also sometimes babies that have a milk protein allergy also have a soy allergy because the soy protein and milk proteins are very similar to each other, so they can mimic each other. So some parents will switch from a milk formula to a soy formula and not see any difference. And that's the reason because they can kind of be similar allergies and that.

Once the baby gets older around when they're starting solid foods, then we think also they could still have milk protein allergy, but we also think of allergies like the typical allergies you think of that caused the wheezing and the hives and things like that. Those allergens are typically peanuts, tree nuts. So tree nuts are things like almonds, pecans, and things like that. Shellfish, thin fish, dairy, eggs, wheat, and soy.

Amanda: Right.

Tina: And then in terms of intolerances, the two that I think we talk about most common are lactose intolerance. It's different than a milk protein allergy. A lactose intolerance means that you have trouble breaking down the sugar in the milk itself. And that we generally don't see in babies. That's usually more toddlers and above. Usually you don't see it before the age of two, typically. And then also a lot of, there's right now a lot of talk about gluten intolerance as well. Again, not something we typically see with babies. That's usually older children.

Amanda: Right. And so how do you know if a baby has an allergy or intolerance? What are some of the signs that you would typically see?

Tina: So this is definitely something where, especially when it comes to like a milk protein allergy or if you're concerned that your child is having an issue with dairy or milk protein, I would say go to your Pediatrician or go to your doctor right away and talk about it because it can actually be, especially the newborns and younger infants, it can be kind of tricky to hash out what is an allergy versus what is an intolerance. And part of that is because a good amount of babies with reflux will actually respond to a milk-free diet. So it's not that they are actually having a milk protein allergy. It might be a milk protein, more like intolerance, but it's making the reflux worse.

So although it's not having those harmful effects like what we were talking about before, like a true allergy where it can cause you to have ultimate harm and your body and baby not gain weight and things like that. It can make them fussy and irritable and make the reflux worse.

So sometimes we'll actually recommend a milk-free formula or a milk-free or mom to go on a dairy-free diet if she's nursing for the reflux. That's not actually a milk protein allergy. So that's why I say definitely if you're concerned about it, definitely go to your doctor so that you can discuss your specific baby and their specific symptoms because it can be a little bit of an overlap in that age group.

But the hallmark, again, of a milk protein allergy would definitely be if they are vomiting after each feed, and vomiting I mean like, but very profusely not just spit up and moving on. I mean forceful vomiting and if they're having any bloody stool, those are definitely hallmarks of a milk protein allergy. But sometimes there's a little bit an interaction between the two. It definitely takes a little more discussion with you and your doctor to hash out what's what.

Amanda: And this is something that I see commonly around some of my own friends, is that other mothers have suggested going off milk or changing the baby from cow's milk formula. Is this something that should really only be recommended by a Pediatrician or a Doctor rather than just from friends?

Tina: Absolutely.  I can't emphasize that enough. If you're going to make any changes to your baby's diet, then I would definitely recommend talking to your doctor or talk to your Pediatrician, talk to your GP about it prior to making that change.

My own daughter had reflux that was responsive to a milk-free diet, and I can tell you as a nursing mom, a dairy-free diet is not easy to do. So before you put yourself through that, you might want to also make sure that that's something that would be helpful. But also anytime you make a change to your baby's diet, it's going to ultimately change what they'll take in the future when you're going to introduce different solids to them. And I would definitely recommend talking to your doctor before making any dietary changes because it can be really eyeopening depending, again, there's a lot of overlap between things and what works for one baby might not work for another. So yeah, depending on the specifics of the situation.

Amanda: Yeah, I couldn't agree more. Definitely. So can allergies or intolerances ever be confused with anything else?

Tina: Definitely. So a lot of times, especially around the six-week mark, parents will come and talk about their baby being really fussy. And so allergies and intolerances can definitely be confused with reflux. But around the six-week mark it also could just be colic, which generally around the four to six week time babies end up stooling less. So parents will think that they're constipated even though a lot of times the stooling patterns can be completely normal for a four to six week old.

Also colicky babies, we don't really know what causes colic, but sometimes parents will come and say it must be the milk, and they've come in at six weeks and they've tried eight different formulas and nothing's making any difference. And they've tried each one for a couple of days here or there and it's not making a difference. And it turns out that it's actually because of colic, which is frustrating, but because there's not much you can do for it, but at least it's reassuring in that you don't have to take something out of their diet and things like that.

So there are definitely overlap between multiple diagnoses, especially in the younger babies. And again, just a fussy infant in general, it can often be attributed to multiple different things, but often times it gets attributed to problems with the formula, problems with the milk, problems with reflux or constipation when it may not be any of them.

Amanda: It may just be that they need more sleep. For example, I know a lot of babies get diagnosed with colic when it's actually just that they have only had three 20-minute sleeps throughout the day. They just need to sleep. They are fussy because they need to sleep.

Tina: Absolutely. 

Amanda: Yeah, definitely. Okay, well, thank you so much for chatting about allergies and intolerances. It's been really informative and thank you very much, Tina.

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About Tina

Tina is a Board Certified Pediatrician through the American Board of Pediatrics, currently she is practising as a General Pediatrician in Virginia.

She did her Undergraduate Degree at Boston College and then went on to Dartmouth, where she received a Masters in Public Health from The Dartmouth Institute for Health Policy and Clinical Practice (https://tdi.dartmouth.edu/). She then went to Medical School at Rutgers University—Robert Wood Johnson Medical School (http://rwjms.rutgers.edu/), where she graduated with honors. She completed her Pediatrics residency at the Children's Hospital of the King's Daughters in Norfolk, Virginia (https://www.chkd.org/), where she currently lives with her husband and daughter.