Synopsis
Recognise physiological regurgitation, identify reflux disease and alternative pathology, avoid unnecessary tests and acid suppression, use feed assessment and stepwise management, and give families safe sleep and escalation advice.
- Gastro-oesophageal reflux is passage of gastric contents into the oesophagus and is common in infancy. In a thriving comfortable baby, visible regurgitation is usually physiological and resolves by 12–18 months.
- Diagnose uncomplicated reflux clinically. Do not routinely investigate a well infant with effortless regurgitation, normal examination and satisfactory growth.
- First-line for a breastfed infant with frequent regurgitation and marked distress is a skilled breastfeeding assessment addressing transfer, oversupply, positioning and attachment while continuing breastfeeding.
- For a formula-fed infant, review feeding history and volume first. Reduce only if excessive, then trial smaller more frequent feeds while preserving the appropriate total daily amount.
- If distress persists, trial a thickened formula. If this fails, stop the thickener and consider an alginate for 1–2 weeks, with review; do not combine alginate with an already thickened feed without specialist advice.
- For a breastfed infant with persistent distress after assessment, NICE allows an alginate trial for 1–2 weeks while breastfeeding continues.
- Do not prescribe proton-pump inhibitors or H2-receptor antagonists for isolated visible regurgitation. Consider a time-limited 4-week acid-suppression trial only when regurgitation accompanies feeding difficulty, distress or faltering growth after reassessment.
- Always place the infant supine for every sleep on a firm flat surface. Do not use prone or side sleep, cot elevation, wedges or positioners as reflux treatment.
- Cow's-milk protein allergy, UTI, gastroenteritis, overfeeding, dysphagia, pyloric stenosis and obstruction can imitate reflux; history and red flags decide the pathway.
- pH-impedance monitoring is a specialist reference test when correlation of acid and non-acid reflux with persistent symptoms will alter care; it is not a routine confirmation test.
- Explain the natural history and agree what deterioration means. Family exhaustion deserves practical support even when medication is unnecessary.
Key red flags
Bilious green vomit indicates possible intestinal obstruction and requires urgent surgical assessment.
Progressively forceful or projectile vomiting, especially before 2 months with hunger and poor growth, suggests pyloric stenosis.
Haematemesis, melaena, blood in stool, abdominal distension or a palpable mass is not explained by simple reflux.
Fever, lethargy, bulging fontanelle, seizures, dysuria or persistent inconsolability suggests infection, neurological or other systemic disease.
Coughing, choking, cyanosis, wet breathing or recurrent pneumonia during feeds suggests aspiration or swallowing dysfunction.
Onset after 8 weeks, persistent vomiting beyond 1 year, faltering growth or feeding refusal warrants reassessment for another diagnosis.
Investigation priorities
Distinguish physiological reflux, disease and red-flag mimics.
Management branches
Regurgitation is effortless, growth and examination are normal and no red flag is present.
- Explain natural resolution and continue responsive milk feeding.
- Observe technique and avoid excessive volumes while maintaining nutritional needs.
- Give safe-sleep and explicit return advice; do not prescribe routine acid suppression.