Dear Krista,
Thank you for your query at DoctorSpring.com
You have very elaborately explained the problems that your daughter has been having. The structured description is so well written that it could easily have been passed off as written by a fellow pediatrician.
I have gone through the history provided by you in detail and my diagnosis, based on the information provided by you is severe gastro esophageal reflux.
Let me explain the problem in simple language. Normally, a circular band of muscle, called the lower esophageal sphincter (LES), separates the stomach from the esophagus. After food enters the stomach, the LES contracts, acting like a one-way valve that closes and prevents the stomach contents and acids from regurgitating, or refluxing, back up into the esophagus. In some babies, the LES is temporarily immature, so it allows partially digested stomach contents and acids to be refluxed. This irritates the lining of the esophagus and causes the pain. In some infants, such as your daughter, the same problem can present with more severe features that we label as the SANDIFFER SYNDROME. In this entity, the severe gastroesophageal reflux forces the baby to adopt abnormal neck positions, that you have very rightly highlighted.
The following feeding and positioning tips will help minimize her acid reflux.
For an infant with GER, an upright position helps, since gravity helps keep the stomach contents down. Sit with her on your lap with her head nestled against your chest. Keep her in this position for at least thirty minutes after a feeding.
One more advice that can help is feeding her twice as often, half as much. It stands to reason that if a smaller volume of milk s given, it will be digested faster and there will be less to spit back up.
Regarding the content of feeds, I am glad you chose to stop the formula feeds. Breast milk has many advantages over formula, especially for a baby with GER. It's digested faster than formula, which minimizes reflux, and it contains enzymes that aid digestion.
Positioning the baby appropriately can also help. Lying flat doesn't provide the benefit of gravity to keep food down. You can elevate the head of the crib about 30 degrees. This slight incline is often enough to lessen nighttime regurgitation. While it's certainly safest to put your baby to sleep on his back, if she simply won't sleep in that position, encourage her to sleep on her left side.
Now coming to the pharmacological treatment, kindly start her on Oral Lanzoprazole 1 mg per kg per dose once daily for at least 2 weeks. You can stop ranitidine.
She requires an ultrasound abdomen specifically looking for relative positions of superior mesenteric artery and vein. She also requires an upper gastrointestinal endoscopy to look for other causes. This can be carried out under the supervision of a pediatric gastroenterologist. She also needs to be monitored closely for her weight gain and comfort level so that we can assess her response to therapy objectively.
Lastly, I personally do not feel that she requires a rectal biopsy as her clinical picture does not fit into that of Hirschsprung disease.
Hope she recovers soon. Please feel free to clarify if any of my suggestions are unclear.
Regards
Dr. Saptharishi L G

Dear Krista,
I am glad that you found my suggestions helpful. Regarding the newer investigations, ultrasonography of the abdomen with a specific focus on two things: 1. Measurement of thickness and length of gastric pylorus to rule out an Idiopathic hypertrophic pyloric stenosis. 2. Assessment of relationship of SMA and SMV to rule out a malrotation complex.
The above investigation is absolutely harmless and non invasive with no radiation exposure. We can decide regarding the need for upper gastrointestinal endoscopy if the ultrasonography work up is NEGATIVE. Though upper GI endoscopy is slightly more invasive and requires sedation, it may give valuable information regarding tone of her sphincter, degree of reflux, degree and severity of reflux esophagitis. Sometimes, endoscopy could pick up surprising congenital anatomical variations as well. So, my personal advice is to get Test no. 1 immediately and may be wait for two weeks to assess response to Lanzoprazole and then pursue test no.2 if she continues to be symptomatic.
Weaning her from medicines need not be done. If she has good response to the Lanzoprazole therapy, we could continue using it.
Soothing her throat is important but not at the cost of risking other harm. So administering tea would not be advisable. I would recommend that you try a spoon of Luke warm water ( ensure adequate cleanliness, preferably boiled water subsequently brought down to just around room temperature). If that also does not help, you could try giving her small amount of honey. In my personal experience, it works for many infants. But, it is important that honey can be a source of infections like botulism, so every care has to be taken to procure honey of the highest quality.
Regards.

Dear parent,
Excessive gas or flatulence in such a young infant can be due to one of the following causes:
1. Physiological variation
2. Inadequate digestion of lactose content of milk such lactose intolerance, etc.
3. Mother ingesting foods that produce flatulence. Though modern medicine rubbishes the above cause, many mothers report increased flatulence in their babies on ingesting foods such as potato, pulses, beans, etc
You could modify the content of your food, increase content of fibres and decrease foods that lead to flatulence. If it persists despite the dietary change in mother, it could be most likely due to a physiological variation. You could consider ignoring it as long as the child continues to gain weight adequately and remains active.

Dear Krista,
Physiological variation essentially means that each infant is DIFFERENT and may have his/her idiosyncrasies. Just like adults differ from each other in how gassy they are, children too are different. It does not mean she is going to be gassy all her life and no one can predict that.
I think you harbor a misconception regarding LACTOSE INTOLERANCE. Your staying away from dairy products has nothing to do with your baby being lactose intolerant or tolerant. Breast milk and essentially all animal milk have LACTOSE. There are lots of myths and misunderstandings about it:

• There will not be less lactose in the breastmilk if you stop eating dairy products.
• There is no relationship between lactose intolerance in adult family members, including in the mother, and in babies. They are different types of lactose intolerance.
• A baby with symptoms of lactose intolerance should not be taken off the breast and fed on soy-based or special lactose-free infant formula.
• Lactose intolerance is very different to intolerance or allergy to cows' milk protein.

The amount of lactose in breastmilk is independent of the mother's consumption of lactose and hardly varies. Lactase is the enzyme that is required to digest lactose. Lactose intolerance occurs when a person does not produce this enzyme, or does not produce enough of it, and is therefore unable to digest lactose. If it is not digested and broken down, it cannot be absorbed. If this happens, the lactose continues on in the digestive tract until it gets to the large bowel. It is here that bacteria break it down to make acids and gases, as is seen in your baby. The symptoms of lactose intolerance are liquid, sometimes green, frothy stools and an irritable baby who may pass wind often. If a baby is lactose intolerant, the medical tests ('hydrogen breath test' and tests for 'reducing sugars' in the stools) would be expected to be positive. However they are also positive in most normal breastfed babies under 3 months. Their use in diagnosing lactose intolerance in young babies is therefore open to question. By asking you to stay away from dairy products, your physician has tried to rule out COW MILK PROTEIN ALLERGY or ANIMAL MILK PROTEIN ALLERGY in your child.
Wishing her a speedy recovery.