Gastro-oesophageal reflux is when the contents of the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
Contributing factors to reflux in infants include:
- Immature lower oesophageal sphincter
- Shorter oesophagus
- Slower gastric emptying
- Liquid diet
It is normal for a baby to reflux and regurgitate feeds. Reflux in infants is not concerning, provided there is normal growth and the baby is otherwise well. It usually improves as they grow, and over 90% stop by 12 months.
Presentation
Signs of problematic reflux in infants include:
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Chest infections
- Poor weight gain
Children over one year may experience similar symptoms to adults, such as:
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
Causes of Vomiting in Infants
Vomiting in infants and children is non-specific and often not indicative of pathology. Possible causes include:
- Overfeeding
- Gastro-oesophageal reflux
- Cow’s milk protein allergy
- Pyloric stenosis (projectile vomiting)
- Gastritis or gastroenteritis
- Substances (e.g., medications or toxins)
- Appendicitis
- Infections (e.g., UTI, tonsillitis, otitis media or meningitis)
- Constipation
- Intestinal obstruction
- Diabetic ketoacidosis
- Migraine
- Cyclical vomiting syndrome
- Bulimia nervosa
Red Flags
Red flags for serious underlying causes of reflux include:
- Not keeping down any feed (pyloric stenosis or intestinal obstruction)
- Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
- Bilious (green) vomit (intestinal obstruction)
- Haematemesis or melaena (peptic ulcer, oesophagitis or varices)
- Abdominal distention (intestinal obstruction)
- Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure)
- Respiratory symptoms (aspiration and infection)
- Blood in the stools (constipation, gastroenteritis or cow’s milk protein allergy)
- Signs of infection, such as fever (e.g., UTI, tonsillitis, otitis media or meningitis)
- Rash, angioedema and other signs of allergy (cow’s milk protein allergy)
- Apnoeas (may indicate serious underlying pathology requiring urgent assessment)
Management
In simple cases, explanation, reassurance and practical advice are adequate. Advice includes:
- Small, frequent feeds
- Burping regularly to help milk settle
- Not over-feeding
- Keeping the baby upright after feeding (not lying flat)
Breastfeeding advice and support is indicated for breastfeeding mothers.
More problematic cases may additionally require medical treatment. Options include:
- Gaviscon Infant mixed with feeds (first-line if breastfed)
- Thickened milk or formula (thickeners and specific anti-reflux formulas are available) (first-line if formula-fed)
- Proton pump inhibitors (e.g., omeprazole)
Specialist referral for further investigations (e.g., barium swallow, oesophageal pH monitoring and endoscopy) may be required where there are red flags, atypical features or an inadequate response to treatment.
Sandifer Syndrome
Sandifer syndrome is a rare condition affecting infants that causes brief episodes of abnormal movements associated with gastro-oesophageal reflux. The infants are usually neurologically normal. The key features are:
- Torticollis (forceful contraction of the neck muscles causing twisting of the neck)
- Dystonia (abnormal muscle contractions causing twisting movements, arching of the back or unusual postures)
Patients are referred for specialist assessment. Alternative diagnoses (e.g., infantile spasms and seizures) need to be excluded. The condition tends to resolve as the reflux is treated or improves. Generally, the outcome is good.
Last updated February 2025
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