Reflux in babies: symptoms, what helps and when to worry

The NHS defines reflux as when a baby brings up milk, or is sick, during or shortly after feeding. It usually happens because the ring of muscle inside the baby’s food pipe (oesophagus) can be weak, which allows milk to come back up easily. The muscle gets stronger as the baby gets older and the reflux should stop.

NICE’s guideline on reflux in children and young people calls this gastro-oesophageal reflux (GOR), a normal physiological process in infancy, often without any symptoms and more frequent after feeds. In many infants it comes with visible regurgitation of feeds. NICE reserves the term gastro-oesophageal reflux disease (GORD) for reflux that causes symptoms severe enough to merit medical treatment, or complications such as inflamed oesophagus.

In practical terms, most babies who bring up milk have ordinary reflux and no disease. NICE tells clinicians to recognise regurgitation of feeds as a common and normal occurrence in infants that does not usually need investigation or treatment, and to manage it by advising and reassuring parents and carers.

The NHS lists the symptoms of reflux in babies below. A baby may have just one or several, and some babies have none that are obvious.

• 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 because they are not keeping enough food down.

The NHS says it is common for a baby under the age of 1 to bring up a little milk during or shortly after a feed without being distressed. NICE tells clinicians to reassure parents that in well infants, effortless regurgitation is very common (at least 40% of infants), usually begins before 8 weeks, may be frequent (5% of those affected have 6 or more episodes each day), and usually becomes less frequent with time.

NICE also asks that parents are told to return for review if the regurgitation becomes persistently projectile, if there is green or yellow-green vomiting or blood in the vomit, if there are new concerns such as marked distress, feeding difficulties or faltering growth, or if frequent regurgitation persists beyond the first year of life.

NICE lists several red flags that may suggest conditions other than reflux. For example, frequent forceful vomiting in a baby up to 2 months old may suggest pyloric stenosis, bile-stained vomit may suggest a bowel obstruction, and regurgitation or vomiting that starts after 6 months of age or persists after 1 year old suggests a cause other than reflux, such as a urinary tract infection.

The NHS says that if reflux seems to be bothering your baby, you can ask a health visitor for advice and support, get advice about breastfeeding position or how to bottle feed, hold your baby upright during feeding and for as long as possible afterwards, burp your baby regularly during feeds, and make sure your baby sleeps flat on their back, not on their side or front.

The NHS specifically says not to raise the head of the cot or Moses basket. NICE agrees that positional management should not be used for sleeping infants and that babies should be placed on their back when sleeping, in line with NHS advice on sudden infant death syndrome.

The NHS says to ask for an urgent GP appointment or call NHS 111 if your baby has vomit that is green or yellow or has blood in it, is projectile vomiting (being sick with more force than usual), has blood in their poo, has a swollen or tender tummy, has a very high temperature or feels hot, cold or shivery, keeps being sick and cannot keep fluid down, has diarrhoea lasting over a week or signs of dehydration, will not stop crying and is very distressed, or is refusing to feed.

It advises seeing a GP if your baby is not improving after trying things to ease reflux, gets reflux for the first time after 6 months, is older than 1 and still has reflux, or is not gaining weight or is losing weight. It also says to call your GP or 111 if you have any other concerns about your baby.

The NHS says a GP or specialist may want to check whether the baby has an allergy to cow’s milk, because the symptoms can be very similar. If there is no sign of cow’s milk allergy, they may recommend treatments for reflux. For a formula-fed baby that can mean a thickening powder mixed with formula or a pre-thickened formula milk. If thickening does not help or the baby is breastfed, a GP or specialist might recommend medicines that help with distress from reflux and stop the stomach from producing as much acid. Very rarely, surgery might be needed to strengthen the muscle that stops food or milk travelling back up, usually after other things have been tried or if reflux is severe.

NICE sets out a stepped approach. For breastfed babies with frequent regurgitation and marked distress, a breastfeeding assessment by someone with appropriate expertise comes first, then alginate therapy for a trial of 1 to 2 weeks if that has not helped. For formula-fed babies it describes reviewing the feeding history, reducing feed volumes only if they are excessive for the baby’s weight, trying smaller more frequent feeds, then a trial of thickened formula, and alginate therapy if that fails. NICE also says acid-suppressing drugs should not be offered for regurgitation occurring as an isolated symptom, with a 4-week trial considered only in particular circumstances.

For most families reflux is a messy, tiring phase rather than a medical problem, and it fades as the baby grows. The NHS says reflux usually gets better by the time a baby is 1, and NICE puts the figure at 90% of affected infants resolving before their first birthday.

A baby who is happy, feeding and gaining weight is generally doing well, even if there is a lot of laundry. A health visitor, whom the NHS suggests asking for advice and support, can also check how feeding is going.

On the NHS, reflux is usually managed with advice from a health visitor or GP, and the NHS says a baby does not usually need to see a doctor if they are happy, healthy and gaining weight. A GP or specialist can check for cow's milk allergy and consider thickened feeds or medicine if reflux is troublesome. Private paediatric or feeding specialist appointments are available, but NICE advises that regurgitation alone does not usually need investigation or acid-suppressing drugs, so ask what the benefit of any test or medicine would be.