I believe children with reflux are careful eaters-eating a little here, a nibble there in an effort to control the reflux. Some call a child with reflux a picky eater but I believe a child with reflux is careful about eating so she can avoid discomfort and reflux trigger foods.
Many babies with reflux are careful eaters too. Some babies with reflux are comfort eaters, eating a lot and gaining weight well. Other babies with reflux restrict their intake, eating small amounts in an effort to decrease digestive discomfort.
A comfort eater wants to nibble a little bit all day long. Some comfort eaters want to eat day and night, leading to constant eating. A comfort eater may gain weight very readily and appear to be thriving despite the underlying reason for the constant eating: painful backwashing and discomfort. Unfortunately, some comfort feeders over-eat and may spit up and vomit from an overfilled stomach rather than from the underlying reflux.
Digestion may improve with small, frequent feedings so talk to the doctor about whether a different feeding schedule will help. Some babies can regulate their intake and minimize pain better than any other reflux treatment by eating small amounts rather than bigger meals. Each baby is different in this regard.
If comfort feeding is leading to over-eating, parents and caregivers may need to learn new ways of soothing her without food. It can be challenging to replace eating with other forms of comforting such as a pacifier, being held in a sling, rocking in a rocking chair or a sip of water. Keep in mind that learning new ways of coping and comforting will take some time and learning for both of you. Take tiny steps and set realistic expectations for both of you.
If your baby is gaining weight steadily and is through the newborn period, she may need to be gradually weaned from night feedings. Ask your doctor if night feeding is important for her growth or if one or all night feedings can be omitted without compromising her growth. While it may seem like comfort feeding is the most reliable way to get her back to sleep, it may also be the cause of her next wake up call. At night, the lower esophageal sphincter (LES) relaxes so it is easier for stomach acid to escape into the esophagus. If she just had a feeding a few hours ago and her LES is open, she might wake up due to acid burning her esophagus. Further, she is less likely to swallow when she is relaxed and sleeping, another reason for a reflux episode.
Weaning from night feedings is extremely challenging. Most likely, your baby will think this is a very bad idea. I know from personal experience that weaning from night feeding leads to a short term increase in crying and waking. Gradually decreasing the length of the feeding and then eliminating one feeding at a time are steps in the right direction. Even if you have one less wake up call a night, you are making progress both in controlling the reflux and getting everyone some much needed sleep.
Eating too Little
Some babies find that they have two kinds of pain: hunger pain and full tummy pain. Your baby may eat readily for a few minutes to take the edge off her hunger and then abruptly stop. She knows from past experience that when she eats it feels great initially and then it becomes painful again. Unfortunately, she may be too effective in avoiding the pain and even eat too little, affecting her weight. Parents and doctors will study the scale and the weight charts since she might be hovering on the edge of being too little or underweight compared to the average baby.
It is alarming to parents and caregivers when your baby is growing slowing and hovering on the bottom of the growth chart. There is always worry that things will get worse and the trend will go down instead of up. Doctors often worry there isn't a weight buffer for the normal ups and down such as an illness or infection where a short term drop in weight is expected and normal. The doctor may have made a passing remark about using a feeding tube, setting off waves of fear and concern.
It is important for caregivers to let the baby guide the intake as much as possible. Again there is a fine line between getting the nutrients, calories and fluids needed to maintain weight and grow and careful eating. The doctor may have given you targeted amounts of calories and ounces for each day. Some babies just have a hard time with these amounts and seem to under-eat at each feeding, adding to the worry and almost compulsive scale watching. At the same time, it is extremely important not to force a baby to eat by tricking her, holding the nipple in her mouth, keeping the nibble in her mouth when she has turned away or started to cry. Some doctors and parents set up a feeding schedule so the bottle is offered at intervals and the feeding is stopped at a certain point, even if the baby hasn't finished the bottle. Some babies seem to know when they have had just enough to stay hydrated but remain at the bottom of the growth chart.
There may be much discussion between you and the doctor about how much is enough but not too much. I often hear the parent's side of this discussion. The doctor may have mentioned that the baby needs to eat more or she will need a feeding tube. You may try to add more frequent feedings and use more persistence and insistence about eating. Often this leads to a power struggle. As the baby feels the pressure to eat, she reacts by fearing the bottle, crying when placed in the feeding hold and possibly eating less. Babies are very smart and they can feel our fear and anxiety.
It is very important to have frequent discussions with the doctor and close monitoring of intake and growth during this difficult time in the reflux treatment. There will be many ups and downs and you will have many doubts and questions about her feeding. Is she getting enough? Will she ever grow? Will the feeding get worse? It is so hard to find a balance between eating enough and not too much, growing and staying hydrated. Feeding may look easy but it is hard work when a baby has reflux.