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.
Infants will display the following symptoms between three weeks and 12 months of age:
The main cause of reflux 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 12-14 months of age.
The main cause of reflux is an immature lower oesophageal sphincter muscle
Guidance from NICE advises:
To avoid reflux, advise parents to:
A formula milk, such as Aptamil Anti-Reflux, Cow & Gate Anti-Reflux or SMA PRO Anti-Reflux may be suitable. Formulated with cows’ milk, these:
N.B. Because of their thickening agents, anti-reflux milks typically have different preparation 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 milk and fed through a teat with a larger hole.
Alginate-containing sachets are an alternative to thickened feeds.
If a milk has been tried for a few weeks without success, the cause of the reflux may be an allergy to cows’ milk, in which case an extensively hydrolysed formula milk may be appropriate.
N.B. If vomiting occurs with other symptoms (e.g. diarrhoea and a fever), refer to a GP.
For infants experiencing symptoms of reflux and regurgitation, a feeding assessment is the first line of 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:
1 Reduce the feed volumes, if excessive for the infant's weight
2 Offer a trial of smaller, more frequent feeds, while maintaining an appropriate total daily amount of milk (unless feeds are already small and frequent)
3 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:
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.