Reflux in babies

Gastroesophageal reflux (GOR), also known as regurgitation or posseting, is the passage of gastric contents into the oesophagus. It occurs widely in healthy newborns and infants and is considered normal.15 Incidence of reflux peaks at around 3 months of age. In most cases it resolves without intervention by 6–12 months, coinciding with the maturation of the oesophageal sphincter and the ability to sit upright.16 As long as there are no other symptoms and baby is growing well and seems happy, parents should be reassured that reflux isn’t a major concern.

When could reflux be a sign of something more serious?

Babies with gastroesophageal reflux disease (GORD) experience more troublesome, severe, or long lasting symptoms in addition to reflux, such as poor weight gain and distressed behaviour.17

Advice to parents for managing reflux18

To help with reflux, parents can be advised to try the following:

  • Feed in an upright position and hold the baby upright for 20–30 minutes after a feed
  • Give smaller, more frequent feeds
  • Formula-fed babies should be winded every 2 to 3 minutes during feeding; it should also be ensured the hole in the teat isn’t too big or too small. Parents could consider a trial of an anti-reflux formula.

Parents should be reassured that it is common for babies to bring up milk. However, they should be advised to see their GP or health visitor or return to the surgery if the baby has frequent reflux, is irritable during or after feeds (e.g. arching their back and crying), regularly vomits large amounts up to 2 hours after feeding and starts to fuss or refuse feeds, but accepts a dummy.

Further information and support

National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS). GORD in children. 2009


Recommendations for the management of GOR

The following are appropriate for babies whose symptoms do not indicate the need for early referral:17

  • Reassure parents that symptoms are likely to improve over time
  • In clearly overfed babies, advise restriction of feed volume
  • In bottle-fed infants with frequent regurgitation which causes distress, use the following stepped-care approach:19 
           1. Review the feeding history
           2. Reduce the feed volumes only if excessive for the infant's weight
           3. Suggest smaller, more frequent feeds (while maintaining an appropriate total daily amount of formula)
           4. Offer a trial of thickened formula, as advised by NICE
           5. If unsuccessful, stop thickened formula and offer alginate* therapy for a trial period of 12 weeks. If the alginate therapy is successful continue with it, but try stopping it at intervals to see if the infant has recovered
  • If symptoms remain troublesome, refer the child to a paediatrician

* Do not use in children at risk of dehydration or intestinal obstruction, in those already consuming thickened feeds, in preterm infants, or those with renal impairment or congestive cardiac failure

Learn more 

Guideline recommendations regarding formulas

The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the National Institute for Health and Care Excellence (NICE) recommend parental reassurance and education when trying to help resolve reflux.17,19

They also recommend trialling a thickened formula for uncomplicated GOR in formula-fed infants.19

Starch thickener

Children under 6 months of age can digest starch, a carbohydrate that is used as a thickening agent in certain infant formulas.

SMA PRO Anti-Reflux is thickened with potato starch to offer optimal viscosity in conjunction with high digestibility. This viscosity contributes to the non-reflux of the bolus into the oesophagus. Starch thickened formulas have proven efficacy in reducing the number of daily regurgitation episodes.20-22

 

SMA® PRO Anti-Reflux is designed for the dietary management of babies with significant reflux. SMA PRO Anti-Reflux contains a unique combination of easily digestible starch and partially hydrolysed, 100% whey protein.

References
  1. Department of Health. Infant feeding recommendation. May 2003 Available here.
  2. Best Practice for Infant Feeding in Ireland. Food Safety Authority of Ireland, 2012.
  3. Iacono G et al. Dig Liver Dis 2005; 37: 432–438.
  4. National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summary (CKS): Constipation in children. September 2010. Available here.
  5. National Institute for Health and Care Excellence (NICE). Clinical Guideline. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care (CG99). May 2010.
  6. Tabbers MM et al. JPGN 2014; 58: 258–274.
  7. NHS Choices. Colic. 2014. Available here.
  8. National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summary (CKS): Colic - infantile. November 2014. Available here.
  9. Vandenplas Y et al. Nutrition 2013; 29: 184–194.
  10. Billeaud C et al. Eur J Clin Nutr 1990; 44: 577–583.
  11. Infante D et al. World J Gastroenterol 2011; 17: 2104–2108.
  12. Carnielli VP et al. J Pediatr Gastroenterol Nutr 1996; 23: 553–560.
  13. Yao M et al. JPGN 2014; 59: 440–448.
  14. Limanovitz I et al. The effects of infant formula beta-palmitate structural position on bone speed of sound, anthropometrics and infantile colic: a double blind, randomized control trial. ESPGHAN 2011.
  15. Hyman PE et al. Gastroenterology 2006; 130: 1519–1526.
  16. Ramirez-Mayans J. J Int Pediatr 2003; 18: 78–83.
  17. Vandenplas Y et al. J Pediatr Gastroenterol Nutr 2009; 49: 498–547.
  18. National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summary: GORD in children. March 2015. Available here.
  19. NICE Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people, 2015. Available here.
  20. Indrio F, Di Mauro A, Trove L, Brindise G. Thickened partially hydrolysed milk formula added with L. Reuteri decreases the number of regurgitation in infants and ameliorates gastric motility. J Pediatr and Neonatal Individualized Med 2015; 4 (2)
  21. Indrio F et al. Effect of partially hydrolysed whey formula containing starch and Lactobacillus reuteri on regurgitation and gastric motility: a randomized, controlled trial. Submitted for publication December 2016.
  22. Toporovski M.S., Neufeld C.B., Cuflat C., Magni A.M., Aleixo D., Okana R.T. A comparative study among two different AR formulas and a standard formula in infants with gastroesophageal reflux (GER). (Abstract presented at the 46th Annual meeting of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition: London, May 8-11, 2013). JPGN 2013; Vol 56, Suppl 2:330.
  23. Heyman MB, Committee on Nutrition. Pediatrics 2006; 118: 1279–1286.
  24. Saneian H et al. Iran J Pediatr 2012; 22: 82–86.
  25. Huang Y, Xu JH. Chin J Contemp Pediatr 2009; 11: 532–536.
  26. Moya M et al. Acta Paediatr 1999; 88: 1211–1215.

*Ingredients of all formulas were confirmed by telephoning company carelines dedicated to answering queries about their products (March 2015)

IMPORTANT NOTICE: The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. This product must be used under medical supervision. SMA PRO Anti-Reflux is a special formula intended for the dietary management of bottle-fed babies when significant reflux (regurgitation) is a problem. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 12 months of age. If the baby’s reflux does not improve within 2 weeks of starting SMA PRO Anti-Reflux, or if the baby fails to thrive, the family doctor should be consulted.