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Reflux, or gastro-oesophageal reflux disease (GORD), affects 30 per cent of infants. Also called regurgitation, it occurs when the stomach contents are brought back up into the oesophagus or mouth
Babies often bring up milk during or shortly after feeding. However, babies who repeatedly bring up their food may have a more serious, long-term form of reflux that may need treatment.
Symptoms
Infants will display the following symptoms before eight weeks of age:
- Bringing up milk or being sick during or shortly after feeding
- Coughing or hiccupping when feeding
- Being unsettled during feeding
- Swallowing or gulping after burping or feeding
- Crying and not settling
- Not gaining weight as they are not keeping enough food down.
Causes
The main cause is an immature lower oesophageal sphincter muscle that allows stomach contents to pass back into the oesophagus. As this muscle matures, the frequency of reflux reduces and usually disappears by 12 months of age.
Top tips for easing reflux
- To avoid reflux, advise parents to:
- Try to make each feed as calm and relaxing as possible
- Feed the baby little and often and as slowly as possible with regular pauses
- Use the correct sized teat for the baby (see feeding equipment for information on suitable teats)
- Avoid letting the baby get too hungry so that air isn’t gulped down during a feed
- Wind the baby during as well as after a feed, ensuring there is at least one good burp! (see other considerations for winding tips)
- Keep the baby upright during and after feeding and avoid bouncing or active play after a feed
- Ensure the baby sleeps flat on their back and not on their side or front.
Treatment
Guidance from NICE advises:
- If breastfeeding, a healthcare professional should review mum’s technique
- If formula feeding, a healthcare professional should review the baby’s feeding history and reduce the volume of milk, if excessive for the infant’s weight. A trial of smaller, more frequent feeds can be offered, if appropriate, followed by a trial of thickened formula milk
- Simeticone or lactase drops are not recommended
- Babies who repeatedly bring up their food may have a more serious, long-term form of reflux.
Formula milks for reflux
For formula-fed infants, a special infant formula milk, such as Aptamil Anti-Reflux, Cow & Gate Anti-Reflux or SMA Anti-Reflux, may be suitable.
Formulated with cows’ milk, these specialist milks:
- Are casein-dominant, so they take longer to digest
- Contain a pre-cooked starch or a gum-based thickener (e.g. carob bean gum) that thickens before feeding. The viscosity is maintained and increases in the stomach, making it less likely that the milk will be brought back up during or after feeding
- Can be used from birth until 12 months of age.
N.B. Formula milks for reflux typically have different make up instructions to standard formulas.
Feed thickeners, such as Cow & Gate Instant Carobel, increase the viscosity of a feed, which may prevent it from coming back up. These can be added to expressed breast milk or cooled, boiled water and given as a paste before and during a feed. They can also be mixed with formula and fed through a teat with a larger hole.
If a milk has been tried for a few weeks without success, referral to a pharmacist or GP is necessary because the infant may have an allergy to cows’ milk, in which case an extensively hydrolysed formula may be recommended. Alginate-containing sachets may also be prescribed as an alternative to thickened feeds.
N.B. If vomiting occurs with other symptoms (e.g. diarrhoea and a fever), refer to a pharmacist or GP.
Clinical summary
For infants experiencing symptoms of reflux and regurgitation, a feeding assessment is the first-line approach for both breastfed and formula-fed babies. In formula-fed infants with frequent regurgitation associated with marked distress, NICE recommends that after a review of the feeding history, the following steps should be followed:
- Reduce the feed volumes, if excessive for the infant’s weight
- Offer a trial of smaller, more frequent feeds, while maintaining an appropriate total daily amount of milk, unless feeds are already small and frequent
- Offer a trial of thickened formula.
If this is unsuccessful, thickened feeds should be stopped and the infant should be offered alginate therapy for a trial period of one to two weeks. Breastfed babies whose symptoms do not improve despite the mother following the recommendations of an expert should be given a trial of one to two weeks of alginate therapy. Alginates should only be continued if they appear effective, though they should be stopped at intervals to see if the infant has recovered.
Acid-suppressing drugs (proton pump inhibitors such as omeprazole or H2-receptor antagonists such as ranitidine) should only be prescribed for infants with overt regurgitation and either unexplained feeding difficulties (such as refusing feeds, gagging or choking), distressed behaviour or faltering growth. Metoclopramide, domperidone or erythromycin should not be offered without specialist advice.
Gastro-oesophageal reflux disease (GORD) differs from the common and normal regurgitation of feeds that affects many infants in that the symptoms – usually pain or discomfort – are either severe enough to warrant medical treatment, or are causing complications such as oesophagitis or pulmonary aspiration. NICE clinical guidance states that premature infants and children with complex, severe neurodisabilities, both of whom have a high incidence of GORD, should be under specialist care, which will include management of this condition.
Red flag symptoms to be aware of include:
- Frequent projectile vomiting, which suggests hypertrophic pyloric stenosis
- Bile-stained vomit (intestinal obstruction)
- Haematemesis (upper GI blood)
- Blood in stool or diarrhoea (bacterial gastroenteritis or infant cows’ milk protein allergy)
- Meleana (black, foul smelling stools)
- Abdominal distension or tenderness (intestinal obstruction)
- Not gaining weight or losing weight
- Dysphagia (swallowing difficulties)
- Bulging fontanelle or altered responsiveness.
Symptoms that start after six months of age or persist after the child’s first birthday also warrant investigation, as do systemic symptoms such as fever, altered responsiveness and dysuria.
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