Reflux in infant & child

Also known as spilling or spitting up

In babies, 'spilling' or 'spitting up' stomach contents is a normal process that helps to relieve an uncomfortably full stomach. While spilling is generally not considered a disease and nor does not need medical treatment, there are a few things you can do to cope with your baby's spilling.

Key points about reflux in infants

  1. Up to 70% of health babies spill regularly with a peak around age 4 months. This is because their digestive system (gut) is not yet fully developed.
  2. Most children outgrow spilling between 6 and 12 months. It generally improves as baby becomes more upright, the diet becomes more solid, and the gut function matures.
  3. As long as your baby is healthy and growing normally, spilling should not be a cause for concern.
  4. A more-severe form of reflux, known as gastro-oesophageal reflux disease (GORD), is rare. Symptoms of GORD include poor weight gain feeding difficulties, severe restlessness, and sometimes frequent spilling. If you are concerned your baby may have GORD, see your doctor for diagnosis and treatment.

What causes reflux?

Reflux happens when the stomach contents are released back up into the swallowing pipe (oesophagus). 

  • There is a ring of muscle at the top of the stomach that should close when feeding stops. In babies and young children this valve is underdeveloped and may not close properly, causing food and digestive acids to leak back up from their stomach into the oesophagus. 
  • Sometimes, but not always, milk spills out the mouth. 
  • Reflux usually happens after feeding, however, it can also occur when your baby cries, coughs, or strains. 

In some cases, reflux can be caused by something different:

  • Allergic reaction - an immune response to a food ingredient, most commonly cow's milk protein.
  • Reflux oesophagitis - inflammation of the oesophagus lining due to stomach acid leaking up (refluxing) from the stomach
  • Eosinophilic oesophagitis - inflammation of the oesophagus lining due to build-up of white blood cells (eosinophils). This is usually caused by allergy to cow's milk protein
  • Gut obstruction - a narrowing or blockage of the oesophagus or of the area between the small intestine and stomach (pyloric stenosis).

When to see a doctor

undefinedAs long as your baby is healthy and growing normally, reflux should not be a cause for concern. It is different to vomiting because reflux or spilling is effortless, while vomiting is forceful. Read more about vomiting in children. 

Contact your family doctor if your baby:

  • brings up a large amount of milk after most feeds
  • spits up forcefully (projectile vomiting)
  • spits up green or yellow fluid
  • is fussy and unhappy between feeds
  • arches her back or seems to be in pain after most feeds
  • is not gaining much or any weight
  • has breathing problems
  • starts vomiting at age 6 months or older.

Irritability and crying

Reflux is commonly blamed for causing irritability in babies. However, it is very normal for babies to wake frequently and cry lots especially between about 2 to 8 weeks of age. Read more about how to cope with a crying baby

How long does reflux last?

  • Reflux usually begins before babies are 8 weeks old and may continue until approximately 4 months of age.
  • Most babies get better before they are 1 year old as their digestive system matures, as they become more upright, and as their diet becomes more solid.
  • A few children will still experience reflux after 1 year of age. If your toddler or older child has reflux and it is causing them distress, take them to see your family doctor. 

What are the treatment options for reflux?

Reflux does not usually need any special tests or treatment, but while your baby’s digestive system is still developing, there a few things you can try to cope with it.

Position
  • During feeding: Avoid feeding your baby in a lying-down position. Try to keep your baby’s head upright while feeding.
  • After feeding: Keep your baby upright for 30 minutes – usually over your shoulder. Avoid putting your baby in a car seat immediately after feeding because this can make reflux worse.
  • Sleeping: It is important for your baby to sleep on their backs to prevent sudden infant death syndrome. You can try raising the head end of the cot slightly so your baby’s head is higher than their legs. Do this by putting thick books beneath the cot legs, or put a folded towel under the head end of the mattress (don't use a pillow with any baby less than one year old). 
Feeding frequency
  • Give your baby smaller feeds more often, unless the feeds are already small and frequent.
Burping or winding
  • Burp or wind your baby a few times during each feeding. Do it when they pause and look around rather than interrupting their feeding rhythm.
  • Only burp for a minute or less and stop even if your baby doesn't burp. Some babies don't need to burp.
Bottle-feeding
  • If your baby is formula-fed, consult your lead maternity carer, local Plunket nurse or doctor about changing to a hypoallergenic formula. The symptoms of cow's milk allergy or intolerance can be very similar to the symptoms of reflux. A trial of at least 14 days is recommended before a diagnosis can be made.
  • Try a different nipple (or teat) on the bottle, some nipples cause your baby to swallow air while feeding.
Nappies
  • Avoid tight nappies and clothing around the tummy.
Smoking
  • Avoid exposure to tobacco smoke (second-hand smoke).

When to use feed thickeners and other medication

If you have tried the suggestions above and nothing seems to be working, talk to your lead maternity carer, local Plunket nurse or doctor. They may be able to suggest other strategies and discuss the use of feed thickeners and other medications to reduce the spilling, particularly if it is accompanied by significant pain or growth problems.

  • Feed thickener is added to baby formula with the idea that it makes the formula heavier and less likely to rise back up the oesophagus.
  • Medication such as Infant Gaviscon works as an antacid (to neutralise stomach acids) and a thickener. It can be given to breast-fed infants in place of thickened formula.
  • Medication such as omeprazole may be considered for the small number of babies that have GORD.

Be prepared for spills – some practical tips

Looking after a baby who's constantly spilling can be frustrating. Being prepared can help you manage the situation:

  • Place a towel or flannel over your shoulder, when you are carrying your baby upright.
  • Dress your baby in vests and sleepsuits, as they're easy to wash. 
  • Pick a special 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.
  • Pack extra sets of clothes for you and your baby, should you need it. Also carry a a bag for soiled clothing.

Support

If you are coping with a baby who cries constantly and won't sleep, it's easy to feel overcome and exhausted. It can be helpful to get support for yourself and talk to others about managing your baby’s reflux from day to day.

Crying over spilt milk Phone 0800 380 517. Gastric Reflux Support Network New Zealand.
Plunket 0800 933 922. New Zealand's largest provider of support services for the development, health and wellbeing of children under 5. 

Learn more

Infant reflux Mayo Clinic, USA, 2013
Split Milk - What is gastric reflux? Gastric Reflux Support Network NZ, 2015
Spilt milk For parents who are coping with infants who spill but do not meet the criteria for gastric reflux. Gastric Reflux Support Network NZ, 2016

Credits: Health Navigator Editorial Team. Reviewed By: Nir Fireman, Auckland DHB (5 May 2017)