Reflux in babies

Almost every baby brings milk back up, and almost always it means nothing at all. A newborn's stomach is tiny, the food is entirely liquid, feeds are frequent, and the ring of muscle at the entrance to the stomach still closes poorly — with that arrangement some of the milk is bound to come back. What frightens parents is usually the volume: a patch spread across a muslin looks like the whole feed when it is a teaspoon. What follows is not an attempt to talk you out of worrying, but a boundary: which signs show that something more than reflux is going on, and when your baby needs to be seen without delay.

Bringing milk up and vomiting are not the same thing

The difference is not the amount, it is the effort. Bringing milk up happens by itself: the baby has just fed, turns or stretches, and milk runs out of the mouth, sometimes down the nose, usually silently and without any change of expression. The baby is not upset and a minute later is ready to feed again.

Vomiting looks different. It is preceded by strain: the baby goes pale, becomes restless, the tummy contracts and the contents are thrown out with force. After vomiting a baby usually cries, looks worn out and does not want to feed straight away.

It is worth learning to tell them apart, because everything else rests on that distinction. Bringing milk up in the first year is a property of the age. Repeated vomiting is a symptom, and some of its causes need a same-day appointment.

Why it happens and when it stops

Reflux has three causes, and all three go away on their own as the baby grows.

• The ring of muscle between the oesophagus and the stomach does not yet work as a tight valve in a newborn — it is more like a door left ajar; by the first birthday it closes reliably.
• Food in the first six months is entirely liquid, and liquid travels back up more easily than anything thicker. Simply starting solids reduces the spitting up noticeably.
• A baby spends nearly all day lying down. As soon as a child starts to sit, and then to stand, gravity moves onto their side.

Typically the spitting up is noticeable from the first weeks, peaks around three or four months and fades through the second half of the year; by the first birthday it has stopped in almost every child. No treatment is needed for that — time is.

The rule of thumb doctors use is simple: look at the baby, not at the laundry. If your baby is gaining weight, takes the breast or bottle willingly, wets nappies as usual, is settled between feeds and is developing for their age, then reflux needs no tests, no medicines and no change of formula, however much of it there seems to be. Of a baby like that it is fair to say that the one suffering from reflux is the washing machine, not the child.

Signs that mean seeing a doctor

These, on the other hand, do not fit under "it is just the age" and mean your baby should be seen without waiting for a routine appointment:

• poor weight gain, no weight gain at all, or weight loss;
• refusing feeds, crying and turning away from the breast or the bottle;
• vomiting that shoots out with force, across a distance, and episodes that are becoming more frequent by the day;
• blood in the vomit, either bright red or looking like coffee grounds;
• vomit stained green;
• blood or mucus in the nappy;
• arching the back and screaming during a feed or straight after it;
• a new cough, noisy or wheezy breathing, or repeated chest infections;
• a swollen tummy that feels hard;
• fever, lethargy, unusual sleepiness;
• nappies staying dry for long stretches, a sunken fontanelle, crying without tears;
• reflux appearing for the first time after six months, or still there after the first birthday.

If your baby has had an episode of turning blue, going floppy or stopping breathing, that is a call for an ambulance (in Europe the single number is 112), not an appointment.

Forceful vomiting in the first weeks

This one deserves its own section, because behind it sits a condition that is easily mistaken for ordinary reflux and is put right by an operation. Pyloric stenosis is a thickening of the muscle at the stomach outlet that stops food passing onwards. It usually shows itself between the second and eighth week of life, more often in boys and more often in first babies.

It is recognised by the way it builds. At first the baby brings milk up like any other; then the vomiting becomes stronger and larger, is thrown out across a distance and follows almost every feed. There is no blood and no green in it, but straight after vomiting the baby demands to feed again — they are hungry, because nothing is reaching the bowel. After that weight gain stops, the baby loses weight, nappies stay dry and there is hardly any stool.

The diagnosis takes a few minutes on an ultrasound scan, the operation is straightforward, and afterwards the baby feeds normally. The only dangerous part is waiting: a week of watching is enough for a baby to become dehydrated. So forceful vomiting that is getting worse in a baby under two months means being seen the same day.

What actually helps at home

• Feed smaller amounts more often: an overfilled stomach returns milk on volume alone.
• Hold your baby upright during the feed and for at least twenty to thirty minutes afterwards, in your arms or in a sling — but not in a car seat or a bouncy chair, where the baby folds in half and presses on their own tummy.
• Pause to let the wind come up, both partway through the feed and at the end.
• Check the latch: a baby who takes the nipple only will swallow a lot of air. With a bottle, look at the hole in the teat — too large and the flow is more than the baby can manage, too small and they have to suck hard and take in air. Keep the teat filled with milk.
• Do not jiggle, bath or put your baby on their tummy straight after a feed.
• Do not fasten the nappy or the waistband tightly over the tummy.
• Nobody smokes in a house with a baby in it: tobacco smoke makes reflux worse, among everything else it does.

What is not worth doing: working through one formula after another hoping to find the right one, giving gripe water and other colic remedies with no proven effect, or adding thickeners on your own. Formula is worth changing on a doctor's decision and with a particular purpose, not at random.

Sleep on the back and flat, whatever the reflux

This is the point where instinct misleads people most. It feels logical to raise the head of the cot, put something under the mattress or lay the baby on their side so the milk stays down. It should not be done: reflux is not an exception to the rules of safe sleep.

• A healthy baby sleeps on their back, for every sleep, at night and in the day.
• The surface must be flat and firm. Tilted mattresses, rolled towels, positioning cushions and wedges do not reduce reflux, and they do let a baby slide down into a position they cannot get out of.
• Car seats, bouncy chairs, swings and prams are not places for a long sleep at home: in them the head falls forwards and closes off the airway.
• There should be no pillows, duvets, cot bumpers or soft toys in the cot.

The fear that a baby will choke while lying on their back is understandable, but it does not hold up: on the back, milk that comes up goes back down the oesophagus rather than into the airway. Sleeping on the front or the side does not lower the risk, it raises it appreciably.

When cow's milk protein allergy is behind it

There is a condition that looks like severe reflux and is managed completely differently: allergy to cow's milk protein. It occurs in formula-fed babies and in breastfed ones alike, because the protein reaches the baby through the mother's milk.

What allows you to suspect it is that the complaint never comes alone. Alongside heavy spitting up and distress at feeds there is usually something else: a rash or stubborn eczema, mucus and streaks of blood in the nappy, diarrhoea or constipation that will not settle, poor weight gain, a blocked nose. Often someone in the family has asthma, eczema or a food allergy.

The only way to check is a trial of exclusion: a breastfeeding mother takes dairy out of her own diet, or the baby is put on an extensively hydrolysed formula, and the result is judged after two to four weeks. Doing this on your own and open-endedly is not the way — a dairy-free diet has to be put together properly and also stopped at the right time, and what confirms the diagnosis is reintroducing the food under medical supervision. Standard allergy testing adds little here.

Medicines: why they are prescribed more often than needed

Acid-suppressing drugs — proton pump inhibitors and H2 receptor blockers — have come to be prescribed to babies very widely, and this is a case where it is worth asking your doctor a question. In most infants the problem is not acid but volume and an immature valve: the drug makes the milk that comes back up less acidic, but it does not stop it coming back up. In babies who simply spit up a lot and cry a lot, studies have not shown a lasting benefit.

They are not harmless either. Stomach acid is part of the defence against infection, and when it is suppressed for long periods babies get gut and chest infections more often; an effect on the absorption of iron and calcium is also under discussion.

None of that means they are never needed. They have a place when there is confirmed damage to the oesophagus, pain on swallowing, or refusal to feed with weight loss — that is, when reflux has stopped being a matter of age and become a disease. They are given as a course with a review date set in advance, not "until it passes".

As for the rest: thickeners and pre-thickened formula reduce the visible spitting up but do little for how the baby feels, and they do not suit everyone. Surgery for reflux in babies is rare and is kept for severe cases with complications, once everything else has been tried.

Online consultation

A remote appointment settles the main question well: is what is happening to your baby the reflux of this age, or something else. The doctor will go through what the episodes look like and how your baby behaves during a feed and afterwards, check the weight gain against the growth chart, watch how you latch the baby on or give the bottle, and tell you what can be corrected today. It is also a convenient way to work out whether there are grounds to suspect cow's milk protein allergy and how to run the exclusion trial properly, or to review a medicine already prescribed — what it is for, for how long and when to stop it. The urgent signs in the list above are not assessed remotely: they need to be seen the same day, and a pause in breathing or a blue colour needs an ambulance.

This material is for information only and does not replace medical advice.