Reflux in babies

Reflux, when the contents of the stomach flow back up the oesophagus, is a common problem in babies younger than 12 months, who may bring up milk during or after feeding.

This reflux causes regurgitation or ‘spitting up’ and is also sometimes called possetting.

A small amount of spitting up is common in babies after a feed. Provided the baby is not distressed, and is generally thriving and gaining weight, this can be considered normal. Usually the food ‘spills’ passively out of the baby's mouth.

Reflux usually settles down soon after solid foods are introduced into the diet. Reflux usually goes away by 12 to 14 months, and rarely affects infants after 18 months of age.

Symptoms of reflux in babies

The main symptom of reflux in babies is regurgitation, or spitting up. This is sometimes described as vomiting, however, technically speaking, vomiting is more forceful than regurgitation.

If your baby is irritable or distressed after feeds, regurgitates frequently, and is slow to gain weight, talk to your doctor.

Babies who have frequent symptoms and/or complications may be diagnosed with gastro-oesophageal reflux disease (GORD). In gastro-oesophageal reflux disease, stomach acid can irritate the oesophagus to such an extent that the baby is in pain. This will often show up as crying and irritability after feeds.

GORD in babies can result in complications, such as:

  • the baby being slow to gain weight, or losing weight;
  • the baby refusing to feed;
  • inflammation and bleeding of the oesophagus (which may result in regurgitating or vomiting material that is blood-stained or looks like coffee grounds, black tarry stools or iron-deficiency anaemia); and
  • inhalation (breathing in) of regurgitated food, causing chronic coughing, wheezing or even pneumonia.

Fortunately these complications are rare, but they are all potentially serious.

Causes of reflux in babies

Reflux is due to delayed development of the ring of muscle between the lower end of the oesophagus and the stomach. This ring of muscle is called the lower oesophageal sphincter.

As the baby grows, the lower oesophageal sphincter should function normally, and food stays where it belongs — in the stomach, and carries on into the intestine. The lower oesophageal sphincter usually functions normally by 12 to 14 months.

Diagnosing reflux in babies

Simple reflux may be diagnosed by your doctor based on the description of your baby’s symptoms and a physical examination. Your doctor will check that your baby is growing as expected, and whether there is any evidence of complications from reflux.

Babies who are gaining weight as expected and are otherwise healthy generally do not need to have any tests. Tests may be recommended for more serious cases, particularly if the baby is failing to thrive. Investigations may also be recommended for babies who do not respond to self-care measures or a trial of treatment.

Your doctor may refer you to a paediatrician (specialist in children’s health) or paediatric gastroenterologist (specialist for children with conditions affecting the digestive system) for tests and treatment.

Tests might include:

  • endoscopy, in which a tiny telescopic tube is passed into the baby's stomach to see what is going on;
  • X-rays or other imaging tests; and
  • oesophageal pH (acidity) and impedance monitoring, which measures acid and non-acid reflux of liquids into the oesophagus.

Treatments for reflux

In most babies who are otherwise well and thriving, no action is needed except to minimise the mess and extra washing necessary when food is regurgitated over the baby's clothing and bed linen. Investing in plenty of bibs and muslin squares may help keep the washing under control.

Some babies will respond to simple self-care measures alone, such as those suggested below. Babies with symptoms that are not relieved with self-care measures, as well as those with more severe symptoms and complications, may need further treatment.

Tips to stop your baby having reflux

Simple measures that you can take to help to help treat reflux in babies include:

  • feeding your baby in a ‘head up’ position;
  • offering smaller, more frequent feeds;
  • burping your baby at intervals during the feed;
  • holding your baby upright for about 20 to 30 minutes after feeds; and
  • in bottle-fed babies, making sure that that the bottle teat is appropriate for the baby’s age.

Thickening feeds is sometimes tried, but with limited success. Thickening involves adding rice cereal (corn starch or commercial food thickeners may also be used) to formula or expressed breast milk.

There are also anti-reflux formulas that may help reduce regurgitation in babies.

Medicines

Medications that reduce the amount of acid in the baby’s stomach secretions may sometimes be prescribed by your doctor.

Medicines are usually only needed in babies who are:

  • not improving with self-care measures;
  • not gaining weight; or
  • have features of gastro-oesophageal reflux disease.

Proton pump inhibitors (PPIs) may be recommended initially. Formulations that are easier to give to babies and children include granules (that can be sprinkled onto food) and tablets that dissolve on the tongue. Alternatively, a different type of medicine that reduces stomach acid secretion – histamine H2-receptor antagonist medicines – may be prescribed.

Surgery

In very severe cases, surgery may be recommended to tighten the lower oesophageal sphincter muscle between the stomach and the oesophagus. Fortunately this is only very rarely required.

When to contact your doctor about vomiting in babies

There are many causes of vomiting in babies, including infections of any sort and a range of other conditions. If your baby is vomiting at times other than shortly after feeding, appears distressed and is not gaining weight, you should see your doctor.

A condition called pyloric stenosis, in which the opening at the lower end of the stomach is partly blocked, is present in about 2 per cent of babies. This causes projectile vomiting, in which large amounts of vomit can shoot out of the mouth, travelling quite a distance.

Sometimes an allergy to cow’s milk protein can cause symptoms similar to reflux.

If your baby is vomiting large amounts, or the vomit is green or yellow, contains blood or looks like coffee grounds, you should seek immediate medical attention.

Last Reviewed: 9 September 2016
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References

1. Gastro-oesophageal reflux in children (published March 2016). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2016 Mar. http://online.tg.org.au/complete/ (accessed Sep 2016).
2. NHS Choices. Reflux in babies (updated 16 Oct 2014). http://www.nhs.uk/Conditions/reflux-babies/Pages/Introduction.aspx (accessed Sep 2016).
3. Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Gastrooesophageal reflux in infants. http://www.rch.org.au/clinicalguide/guideline_index/gastrooesophageal_reflux_in_infants/ (accessed Sep 2016).
4. Royal Children’s Hospital Melbourne. Kids Health Info: Reflux GOR (updated Dec 2010). http://www.rch.org.au/kidsinfo/fact_sheets/Reflux_GOR/ (accessed Sep 2016).
5. National Institute of Diabetes and Digestive and Kidney Diseases. Gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in infants (updated 8 Apr 2015). https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/ger-and-gerd-in-infants/Pages/overview.aspx (accessed Sep 2016).
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