Reflux

What is reflux?

Reflux is when your baby brings up some of their milk. It's also known as possetting or spitting up.

Lots of parents go through this stage, as it affects half of all babies. Reflux usually starts before eight weeks, and both formula-fed and breastfed babies can be affected (NICE 2015a, Tidy 2018).

It can be upsetting when your baby brings up milk. They may cry and fuss and you may worry whether they're keeping down enough milk to nourish them.

Most babies thrive, and reflux is nothing more than a messy and smelly stage they go through. It usually gets better as your baby's digestive system matures (NICE 2015a).

The full medical term for reflux is gastro-oesophageal reflux or GOR. A small percentage of babies have troublesome, severe or persistent reflux, called gastro-oesophageal reflux disease (GORD) (NICE 2015a, Rosen et al 2018).

Premature babies are more likely to be affected by GORD (NICE 2015a, Rosen et al 2018). Babies with life-long medical conditions, such as cystic fibrosis, are also more likely to suffer from GORD (Rosen et al 2018).

What causes reflux?

Reflux happens because of your baby's age and stage of development. Their food pipe (oesophagus) connects their mouth with their stomach. Where their food pipe joins their stomach, there's a valve that opens to let milk in, and shuts to keep it down.

When your baby is only a few weeks old, their food pipe is short and narrow. The valve at the entrance to their stomach isn't strong yet, and it sits just above their diaphragm, the muscle that stretches across their abdomen. These are reasons why the valve can open easily (NICE 2015b).

When your baby's tummy is full, milk and acid can come back up their food pipe, causing them discomfort. You'll probably notice when this happens, but sometimes your baby may swallow the milk, or it may not get as far as their mouth. This is known as silent reflux.

Bear in mind that your baby's stomach is still small (Best Start 2017), so may not be able to hold a lot of milk at once (Bergman 2013, NICE 2015b). As a young baby, they're probably lying down a lot, which makes it easier for milk to come back up (Bergman 2013, NICE 2015b). This is why smaller, frequent feeds work best for newborn babies, and may help to ease reflux (Bergman 2013, Rosen et al 2018).

As your baby grows, the muscles that control the valve will strengthen, their food pipe will get longer and their stomach will get bigger. They are likely to grow out of reflux before the end of their first year (Davies et al 2015, NHS 2016a, NICE 2015a).

Sometimes, reflux is related to another condition that causes a baby's digestive system to work more slowly. This could be because of a cow's milk protein allergy (CMPA) (Ferreira et al 2014, Rosen et al 2018). If you think this could be the case, speak to your doctor or health visitor.

How will I know if my baby has reflux?

Your baby may bring up small amounts of milk (possetting) or occasionally vomit after eating. They may have hiccups and cough and splutter a little (NHS 2016a). Some babies also get wheezy after a milky burp (Halit et al 2018, Rosen et al 2018, Tidy 2018).

Bringing up some milk is normal and, as long as your baby is otherwise well, you don't need to worry about spitting up (NICE 2015a,b, NHS 2016a). You'll soon get used to reaching for a cloth or muslin square.

How can I prevent reflux?

If your baby's reflux is mild, they're still feeding well and aren't too upset by it, these tips may help:

• Try giving your baby smaller, but more frequent, feeds (Bergman 2013).
• Feed your baby in an upright position.
• Hold your baby upright for about 20 minutes after each feed (AAFP 2018, NHS 2016a).
• If you bottle-feed your baby, burp them every two minutes or three minutes during feeds, and make sure that the hole in the teat isn't too large. A teat that's too big means your baby takes in too much milk in one go. (AAFP 2018)

It can be tempting to put your baby down to sleep on their side or front, but always check with your GP or health visitor before trying this. Putting your baby down to sleep on their back reduces the risk of sudden infant death syndrome (SIDS) (Lullaby Trust nd).

When should I take my baby to see a doctor?

Speak to your health visitor or doctor if your baby starts to have reflux after six months of age, or carries on having it after they're a year old. If your baby has reflux before six months, get advice if they:

• Are always bringing up feeds, instead of just now and then.
• Cough or gag while feeding.
• Often have projectile vomiting.
• Are bringing up green or yellow vomit, or vomit that has blood in it.
• Have blood in their poo, which will show as dark flecks.
• Start to refuse feeds.
• Have a swollen tummy.
• Have a fever of 38 degrees C or above.
• Aren't gaining weight.
• Are irritable during or after feeds, crying and arching their back.
  (NHS 2016a, NICE 2015a)

Ordinary reflux shouldn't cause these symptoms, so your doctor will advise looking into what's making your baby ill.

Sometimes, GORD can cause a baby extra problems, including:

• A sore food pipe caused by bringing up stomach acid.
• Bouts of pneumonia, because of milk and acid that's been breathed in.
• Frequent middle ear infections, happening at least every couple of months.
  (NICE 2015a)

It'll help your doctor if you keep a record of your baby's symptoms. If you can, make a note of:

• When your baby feeds.
• When they have reflux most. Is it at night? Just after a feed? A long time after a feed?
• When they have bouts of crying.
• How much your baby is bringing up.
  (Rosen et al 2018)

Bring your baby's red book with you to your appointment, so your doctor can see how your baby has been growing. Your doctor may also ask other questions, for example, whether your baby is around someone who smokes, or whether they've had any medication recently (Rosen et al 2018).

All this information will help your doctor to work out whether your baby needs to be referred to a specialist for extra care, tests or treatment (NHS 2016a, NICE 2015a).

Are there any treatments for reflux?

Usually, it's just a question of waiting for your baby to get better over their first year.

In the meantime, if you're formula feeding, you could try giving your baby their daily allowance in smaller, more frequent feeds. You could also ask your health visitor for advice about using a thicker formula, which may be easier for your baby to keep down. Always speak to your health visitor first before trying thicker feeds, in case they can suggest a better way to help your baby (NHS 2016a).

Cutting out cow's milk

Sometimes, the symptoms of cow's milk protein allergy (CPMA) can be similar to the symptoms of reflux, particularly in babies under six months of age (Ferreira et al 2014, Rosen et al 2018).

CMPA is more common in formula-fed babies than breastfed babies (Breastfeeding Network 2017). If your baby is formula-fed, ask your doctor about giving them a hypoallergenic formula for a couple of weeks to see if it helps (Rosen et al 2018). If you breastfeed your baby, ask your doctor's advice about cutting out milk and other dairy products like cheese and yoghurt, so they can't get into your breastmilk (Rosen et al 2018).

Trying an infant antacid

You could ask your GP about giving your baby an infant antacid. Antacid helps to neutralise the acid in your baby's stomach, so it shouldn't be as painful for them if they bring it up (NHS 2016b). It may also be combined with an alginate, which is a medicine that helps to keep milk and acid in your baby's stomach in the first place (NHS 2016a, NICE 2015a,b).

If you're breastfeeding, you can give your baby infant antacid mixed with cooled, boiled water after a feed (NICE 2015b). You can give your baby the correct dose of the antacid on a spoon or in a bottle (NICE 2015b).

Every two weeks, stop the treatment to see if your baby's reflux is getting better (NICE 2015b). If your baby is still having problems after a couple of months of having an antacid, go back to your doctor (Rosen et al 2018).

Trying a stomach acid blocker

If antacids don't help, you could ask your doctor about treatment with a proton pump inhibitor (PPI), such as omeprazole. These medicines reduce the amount of acid your baby's stomach makes by blocking the actions of acid-producing cells (Ogbru 2016, 2018).

Your GP will only prescribe a PPI if your baby has a sore food-pipe from the amount of stomach acid they're bringing up. It's not suitable if your baby only has reflux with no other symptoms (NICE 2015b, Rosen et al 2018).

There are disadvantages to a PPI as it may give your baby constipation (NICE 2015b, Rosen et al 2018).

How can I cope with reflux?

Looking after a baby who's constantly bringing up feeds can be exhausting. A spurt of regurgitated milk can go quite a distance, covering you, your baby and anything else nearby. You may feel that you constantly smell of sour milk. Try to bear in mind that reflux is very common, so other parents will understand!

Here are some practical tips:

• Dress your baby in vests and sleepsuits, as they're easy to wash. Buy lots so you have a steady supply of clean ones.
• Pick a comfortable sofa or chair for when you're sitting with your baby, and cover it with a throw or sheet. Have a spare cover so you can wash one while using another.
• Use a washable cover on your baby's car seat or pushchair, and again, have a spare so you can wash one and use one.
• Put wipe-down covers on the back seat of your car to protect the fabric. These will also be handy when your baby is older.
• Pack one or two spare tops for you, as well as clothes for your baby and muslin cloths, in your changing bag. Take a few plastic bags for damp, milky clothing.
• White or pale cotton tops won't show milk stains, and can be washed with baby whites.
  

It's important to look after your wellbeing, too:

• Talk to your doctor or health visitor if you're struggling, or even if you just want a little extra reassurance. They'll be happy to help and support you, and to check that your baby is otherwise well.
• See the charity Living with Reflux for more information and support via their community forum.

Find out how much breastmilk or formula milk your baby really needs, and get some tips on coping with vomiting.

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