Reflux usually starts before a baby is 8 weeks old. It usually improves by six months and is gone by the time they turn one year old. Symptoms of reflux in babies include:
Sometimes babies may have signs of reflux, but will not bring up milk or be sick. This is commonly termed ‘silent reflux’.
Other differentials:
In some instances reflux can be caused by a non-IgE cow’s milk protein allergy (CMPA). These children may present with symptoms of reflux alongside dry patches of skin and a history of Green/bloody stools.
In babies where CMPA is suspected Mum should offer a strictly dairy free diet for two weeks to see if this improves symptoms. A true dairy free diet means strictly no dairy at all, and is not the same as a lactose free diet. Dairy should then be re-introduced into the mother’s diet if breastfeeding, or with an ordinary formula if bottle fed. If symptoms return this is enough to diagnose CMPA. Babies should then be referred to a dietician team who can support and help re-introduce dairy at 12 months via the milk ladder.
Goat’s milk should not be offered to babies’ trialling a dairy free diet. They should be prescribed a hydrolysed formula such as Aptamil Pepti 1 or Similac (depending on local formularies
We have separate guidance on managing babies where cow’s milk protein allergy is suspected – please see here:
Cow’s Milk Protein Allergy in Children – Kingston Hospital
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The following are considered ‘Red Flags’ in babies. If any of these are present, the baby will need to be referred urgently to Paediatrics. Same day referrals can be made via switchboard (0208 546 7711) and will go to a phone during the day or Registrar bleep out of hours. If you would like to discuss the urgency of referral, please call the Paediatric advice line, which is held by a Consultant Monday–Friday 9-5.
If frequent regurgitation presents after 8 weeks of age, please ensure that a urine sample is checked. Young babies may present with a urinary tract infection (UTI) with only vomiting, and being unsettled. Samples should be sent for MC&S as dipstick is not reliable in babies.
UTI guidance can be found here: Urinary Tract Infection in Children – Kingston Hospital
Conservative Treatment
Medical Treatment
Some babies may not experience pain or discomfort with reflux, and may just have occasional vomits. In these children Gaviscon or an alternative thickener will be more helpful than Omeprazole.
Gaviscon is still considered as first line treatment for GORD. This however can be very tricky to give to breastfed babies and commonly causes constipation as a side effect.
Gaviscon for children is different from adult Gaviscon as it is works as a thickener as opposed to an anti-acid.
Medicines for Children have a helpful leaflet for parents on gaviscon in babies:
Omeprazole is used as second line treatment. Dosage is outlined in the BNFc under Gastro-oesophageal reflux disease. Omeprazole can take up to 2 weeks to work. Although it reduces the acid in the stomach quickly, it can take around two weeks for any inflammation in the oesophagus to settle. The dose of Omeprazole should be increased as the child gains weight.
Although a syrup suspension of Omeprazole is available, it is not well tolerated as it is very salty, and is not dispensed by most pharmacies. Omeprazole dispersible tablets or MUPS are better tolerated and should be prescribed.
Ensure that when drawing up the Omeprazole after dissolving it that the granules are drawn up and given.
Medicines for Children have produced a helpful leaflet for parents on giving omeprazole:
https://www.medicinesforchildren.org.uk/wp-content/uploads/sites/8/2021/08/Omeprazole-for-GORD.pdf
If a baby has any ‘Red Flag’ symptoms, please refer urgently as above.
Any infant or child presenting with dysphagia, haematemesis or malaena needs same day assessment. Please refer to paediatrics by phoning switchboard on 0208 546 711 and asking for on call paediatrics (this is to the PAU phone during the day and Registrar bleep out of hours)
For babies who do not need same day assessment, but have ongoing symptoms that warrant paediatric assessment, please refer via ERS. It is helpful to know recent growth measurements, as faltering growth will be prioritised for a more urgent appointment. If you are unsure on the urgency of appointment, we are happy to advise via Advice & Guidance on ERS or the non-urgent advice telephone, which is held by a Consultant Monday-Friday 9-5. These include:
For further information and guidance on reflux please visit www.nice.org.uk/guidance/ng1/resources/reflux-regurgitation-and-heartburn-in-babies-children-and-youngpeople-pdf-555907525 to see the NICE guidance
For further information and guidance on CMPA please visit the Allergy UK website at: www.allergyuk.org/information-and-advice/conditions-and-symptoms/469-cows-milk-allergy
www.cry-sis.org.uk is a charity providing advice and support for parents with babies who cry a lot. They have a helpline for parents seven days a week.
