Reflux in infants

(BMJ 2017;357:j1802, supplemented by checking the original guidance)

Not to be referred to as GORD unless the symptoms are interfering with the baby’s quality of life or causing complications (poor weight gain, difficulty sleeping, recurrent chest infections). Otherwise, it’s physiological GOR, minus the D.

Red flag symptoms

  • Frequent projectile vomiting – forceful enough to stain a wall or land across a room. This is associated with pyloric stenosis, especially if starting from third or fourth week in a typically hungry infant who’s failing to gain weight.
  • Bilious vomiting – can indicate intestinal obstruction and requires urgent surgical referral.
  • Blood in vomit, unless swallowed blood from nipple crack etc.
  • Vomiting unrelated to feeding – can be secondary to RICP and hence a sign of NAI.
  • Bulging fontanelle – also sign of RICP
  • Constipation/loose stools – might indicate CMP or lactose intolerance. (This is included on the list of symptoms requiring paediatric referral, which surprises me; surely a trial of a hydrolysed formula is the best first step?)
  • Blood in stool – CMP-induced enterocolitis (again, not sure why requires paeds referral rather than trial of hydrolysed formula)
  • Onset after 6/12 – unlikely to be reflux, may be infection
  • Persisting after 1 year – suggests alternative diagnosis
  • Systemic symptoms (may be infection or RICP)


Usually conservative.

  • For bottle-fed babies, try the following:
  1. Reduce volumes by about 20% but increase frequency to maintain appropriate total daily amount of milk.
  2. If that isn’t successful after 2/52, offer a trial of thickened formula (Aptamil anti-reflux, Enfamil anti-reflux, SMA Staydown).
  • For breastfed babies, advise seeing lactation expert/community midwife.
  • Try keeping babies in an upright position for the first hour or so after feeding, except when sleeping.
  • Always remember to ask how parents are coping.

If these measures fail, consider a trial of alginate. If that doesn’t work, and if the child seems distressed or has poor growth or choking symptoms as well as the vomiting, try a two-week trial of either H2 antihistamine or proton pump inhibitor. If that still doesn’t work, stop the medication and refer to secondary care.

Don’t use prokinetics without specialist advice.


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, Credits 2017, Paediatrics. Bookmark the permalink.

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