Infant Reflux and GORD: Assessment and Management for Healthcare Professionals

Understanding how the gastrointestinal tract works in young babies is important for managing reflux effectively. Although reflux is often used as a general term, it is rarely caused by a single anatomical problem. Instead, it usually happens because several aspects of the newborn digestive system are still immature. The lower oesophageal sphincter (LOS), is associated with reflux and for many infants, is not a fixed barrier. Reflux has been shown to mainly be driven by the high frequency of relaxations in the LOS (Wyllie et al., 2021). These are spontaneous, involuntary episodes in which the sphincter opens independently of swallowing, leading to reflux symptoms.

In adults, a normally functioning LOS responds to swallowing or to clear the oesophagus. In infants, the LOS is more sensitive to stomach distension. When this is combined with a liquid diet and the mostly horizontal position of a young infant, the stomach contents are much more likely to flow back up into the oesophagus (Lissauer & Carroll, 2021).

Reflux often peaks between four and six months of age and then improves as babies become more upright and begin eating solid foods (Hegar et al., 2009). Understanding this normal pattern is important and can lead to healthy babies being overtreated. Treatment is usually only needed when reflux causes complications, such as poor growth, persistent respiratory symptoms, or signs of oesophagitis, such as vomiting blood or unexplained iron deficiency.

Silent reflux can be harder to identify because there is no obvious vomiting. Instead, stomach contents come up into the oesophagus and are then swallowed back down. The discomfort is often related to slow oesophageal clearance, meaning the refluxed contents are not cleared fully. Research indicates that distressed infants may show delayed oesophageal clearance (Salvatore et al., 2018) meaning that acid stays in contact with the oesophagus for longer, causing irritation and symptoms such as back arching, wet burps, and feeding refusal (NHS, 2025). Recognising these behaviours is important in practice, because without visible vomiting, parents can feel their concerns are being overlooked.

In the UK and Ireland, reflux is usually managed with a stepped care approach that starts with simple, practical measures before pharmaceutical options are considered. This is the basis of NICE guidelines (2019), which for breastfed infants recommend that the first step should be a specialist assessment of positioning and attachment (Royal College of Midwives, 2018). Breast milk leaves the stomach more quickly than cows’ milk-based formula, and it contains bioactive factors that may help soothe and repair the lining of the oesophagus. For this reason, health care professionals should make sure feeding technique and attachment have been fully evaluated before considering supplements or other interventions.

In formula fed infantswith frequent regurgitation and distress after feeds, the NICE guidelines (2019) recommend reviewing feeding history first and, reducing feed volumes if they are excessive and then trying smaller, more frequent feeds while keeping the total daily milk intake appropriate. If a baby is taking more than 180 ml per kilogram of body weight each day, the extra stomach distension can trigger reflux episodes more easily (Shaw & Lawson, 2015). In many cases, offering smaller feeds more often can be effective enough to improve symptoms without any further treatment. However, if this isn’t the case, then a trial of thickened, anti-reflux formulas can be offered to formula-fed infants.

When changes to feeding behaviours have been trialled and are unsuccessful with distress in the infant remaining significant, in formula-fed infants, a one-to-two-week trial of a thickened anti-reflux formula may be appropriate (NICE, 2019; BNFC, 2024). These formulas work by increasing the thickness of the feed, helping it remain in the stomach and reducing the symptoms of reflux. Increased viscosity can reduce the backward movement of gastric contents. Research evidence has shown that thickened feeds can reduce the frequency of regurgitation and improve parental satisfaction (Salvatore et al., 2018).

Starch has traditionally been used as a thickening agent, although it may lose thickness after exposure to digestive enzymes (Miyazawa et al., 2007). Alternatively, carob bean gum, which is used in some anti-reflux formulas, is less prone to this breakdown and may help maintain the thickness of the liquid in the stomach. Parents should be deterred from adding baby rice to bottles, as it can change the profile of the feed.

In contrast to feed thickeners, alginates act by forming a viscous ‘raft’ that sits on top of the stomach contents, reducing the likelihood of reflux episodes. NICE (2019) recommends considering a trial of alginates for infants with frequent reflux when breastfeeding assessment and advice have not improved symptoms, or when formula-fed infants continue to experience distress despite appropriate feeding modifications. Alginates may be particularly useful where visible regurgitation is prominent, although they can cause constipation or interfere with the absorption of some medications.

Because alginates and thickened formulas work via different mechanisms, they are not interchangeable. NICE advises not to use alginates and thickened formulas together, as this can excessively increase feed viscosity.

The emotional impact of GORD is often underestimated because it can affect both feeding and sleep. Safe sleep advice recommends that babies sleep on their backs on a flat surface, but for infants with reflux, this position can sometimes seem to make symptoms worse.

The lack of sleep that follows can place parents under strain and may increase the risk of postnatal depression (Neu et al., 2015). In this situation, a health care professional’s role is not only to help parents manage symptoms but also to provide appropriate emotional support and reassurance. This includes acknowledging how challenging things are, while continuing to emphasise the importance of safe sleep habits. Explaining that reflux is a physiological condition, rather than something caused by poor parenting, can also help reduce the guilt and self-blame that often develop when a baby experiences reflux.

Telling the difference between reflux and cows’ milk protein allergy (CMPA) is often one of the hardest parts of assessing feeding problems in infants. Reflux is mainly a mechanical problem related to the development of the LOS, while CMPA is an immune reaction to proteins in cows’ milk (Venter et al., 2017). Clinicians should look for whether symptoms affect more than one body system. Reflux on its own does not usually cause eczema or lower gastrointestinal symptoms such as mucus or blood in the stool. A trial of thickened formula can sometimes help with diagnosis. If the regurgitation improves but the baby remains very distressed, this may suggest that reflux is not the only problem, and an underlying allergy, such as CMPA, should be considered.

Ongoing reflux can affect how an infant experiences feeding and some babies may begin to avoid feeding or develop defensive swallowing behaviours. Weaning at around six months often helps, as solid foods are heavier and may reduce reflux symptoms (Hegar et al., 2009). New textures can be introduced gradually, and feeding should remain calm and pressure-free so that the infant can build a more positive relationship with food.

The management of reflux also needs to take account of social and economic circumstances. Evidence from the UK and Ireland suggests that infants from more disadvantaged backgrounds may be more likely to experience delayed diagnosis or inappropriate prescribing (Li et al., 2024; NICE, 2025). The stepped-care approach depends heavily on parents being able to make practical changes, such as offering smaller, more frequent feeds. For families in temporary accommodation or faced with food poverty, these changes may be harder to put into practice. Healthcare professionals therefore need to adapt their advice to fit the realities of each family’s situation.

Managing reflux is usually a gradual process. For most infants, it improves and resolves after the first year of life, as feeding matures, the lower oesophageal sphincter develops, and babies spend more time upright. For the healthcare professional, providing good care is not just about managing symptoms, but also supporting feeding, reducing parental anxiety and supporting families. By following the stepped-care pathway and using treatments carefully and appropriately, healthcare professionals can provide care that is safe, compassionate, and evidence-based.