Gastro-esophageal reflux, or reflux for short, occurs when the stomach contents, comprising food and stomach acid, are splashed or pushed back up the esophagus or throat. Sometimes they come all the way up the esophagus and out of the mouth, which we call vomiting, and sometimes they come only part of the way, as with heartburn or 'silent' reflux.

Reflux usually occurs because the esophageal sphincter, the 'valve' between the stomach and the esophagus, is not working properly. When functioning correctly, it should only open to allow us to swallow, belch and vomit, and then close immediately. With reflux, this sphincter either stays relaxed or relaxes periodically. Usually it relaxes when the stomach contracts to force food out through to the intestines, thus allowing food, now mixed with stomach acid, back up the esophagus, causing pain (heartburn). If this happens often enough, and if the food and acid sit in the infant's throat for any length of time, the result can be oesophagitis (inflamation or burning of the throat lining).

Reflux often occurs with a motility disorder. (please refer to article on related motility immaturity for more info) Put simply, the throat muscles are uncoordinated, so regurgitated food and acid sits in the throat. In normal circumstances it would be cleared straight away. Like reflux, this is an immaturity that most infants outgrow. This is why some infants don't vomit! This is why thickeners should be used with caution in these infants, as they may make the feed harder to clear from the throat once refluxed. A simple guide to follow with any reflux management strategy is, if you don't notice an improvement in a couple of days, try something else. With any reflux medication you should notice a substantial improvement in about 2 weeks, otherwise refer back to your medical practitioner.

Most babies are born with some degree of reflux, which is outgrown as the digestive system matures. In the majority of cases it causes no discomfort and so no further investigation is needed. Most babies with reflux are happy and thriving, despite vomiting (these infants are sometimes labelled the 'happy chucker'). Some babies will have pain and no vomiting, similar to heartburn in adults. They can cry / scream for a few minutes or hours and seem unsettled and / or irritable most of the day. Some babies vomit and scream. If you suspect that your child is in pain, treatment may be required to manage this condition. Reflux is a treatable condition that, if managed correctly should not cause your baby considerable distress.

Recent studies are showing that food intolerance may play a role in reflux in some babies, and once the food Intolerance is treated, the reflux stops. If you have a reflux child, we suggest you read our section on food Intolerance.

Symptoms

Reflux symptoms vary and thus a baby should only be labelled 'reflux' after consulting your GP, paediatrician or paediatric gastroenterologist. Reflux can be difficult to diagnose, as often the only sign a baby has reflux is that they are irritable and distressed. Sometimes these babies are incorrectly diagnosed as having colic. Colic is in itself an indicator of both reflux and food intolerance.

The number of symptoms exhibited in a reflux infant, is by no means an indication of the severity of the infant's condition. A baby does not have to lose weight to require treatment. If the symptoms persist, then further investigation is warranted. The symptoms of reflux may consist of any of the following:

• Pain, irritability, excessive crying, sudden crying, screaming, colic.

Irritability can cover such symptoms as whingeing, crying, screaming, fussiness and inconsolable behaviour, which may last for varied lengths of time. This is because the esophagus is burning which causes pain.

1. These symptoms can occur at any time of the day or night, during or following the feed, when baby is laid down, or even 30 minutes to 90 minutes after the feed, as this is when the stomach pressure increases to force food out of the stomach into the intestines, but instead forces it back up the esophagus causing intense pain (heartburn).

3. These infants are often described as "colicky" or "windy" because of their irritability and failure to settle after feeds.
4. Reflux infants often appear to be over-sensitive to noise. Basically this is because they are not getting enough sleep.

5. These children can also be happy sometimes when they are distracted e.g. they smile at the doctors, when visiting grandparents or at the shopping centre.

6. Parents often have a "gut feeling" that their child is in pain.

Vomiting

1. Not all infants suffering from reflux actually vomit, but any form of reflux may disturb the baby thus causing crying and irritability.

Those infants that do vomit can:
(a )Merely regurgitate, or posit down their chins and clothing; or
(b) Projectile vomit with food literally being forced out, sometimes through their nostrils. (Be aware - there are other reasons why an infant might projectile vomit. It is important to have these infants seen by a doctor for a correct diagnosis.)

2. Vomit can take the form of: -
(a) Unchanged milk or undigested food;
(b) Curdled milk or partly digested food;
(c) Gastric contents;
(d) Fresh blood or coffee-coloured stain in vomit. (Contact doctor if this occurs).

3. The number of vomits varies; "reflux" infants may vomit after the feed or without discretion - anytime, anywhere, over anybody or anything!

4. The vomiting may lessen when the infant sits up and in some cases worsen when the baby crawls. Some infants may stop vomiting when they become upright and mobile, but still reflux stomach contents into their oesophagus many times a day. This may cause as much or more discomfort to the infant as vomiting. The child may still be symptomatic. If this is the case, further medical treatment may be necessary.

Poor sleep habits

1. Due to their discomfort, reflux babies are often poor sleepers.

2. Some will remain awake all day because of the pain, then crash at night, sleeping eight to ten hours in a row because of exhaustion. Some will be great "cat-nappers", often only sleeping for five minutes at a time before waking in a distressed state. Others fall somewhere in between.

3. Reflux infants tend to be more comfortable in an upright position, thus they generally object to being laid down (especially on their backs).

Poor feeding habits

Reflux babies when being fed, may arch their backs, pull their legs up, squirm, stiffen or scream. They may pull off or interrupt the feed, push the breast or bottle away as they feed, or even refuse the feed, because it hurts. On the other hand they may also comfort feed, eating or drinking constantly, sucking vigorously and be unhappy unless feeding.

Changing formulas is not a cure for reflux, nor is changing from breast to bottle-feeding. Bottle-feeding does not fix reflux, in fact studies have shown that;
"Irritability occurs equally between breast and bottle fed babies. Investigations have found that healthy breastfed neonates had a lower incidence of gastro-oesophageal reflux than those who were bottle-fed."
(Heine, R.G., Jaquiery, A., Lubitz, L., Cameron D.J.S. & Catto-Smith, A.G.'Role of Gastro-Oesophageal Reflux in Infant Irritability' in Archives of Disease in Childhood, 1995, Volume73, p.124)

Failure to thrive or weight loss

A reflux baby may start to fall across percentile groupings in their health charts, starting off in the 40 % grouping and slowly dropping down to the 5% grouping or even off the chart over a period of time. They may also lose weight. On the other hand, if they comfort feed, they may put on weight normally, or even show huge weight gains.

Coughing, respiratory problems, pneumonia, bronchitis, wheezing, asthma, nighttime cough, wet hiccup sounds, apnoea or aspiration.

These symptoms may occur if the baby's stomach contents enter the nose, windpipes or lungs, due to regurgitation.

Food intolerance, colic

Reflux, food intolerance and colic are all due to an immature digestive system, so are all indicators of each other, and can occur together. Food intolerance has also been found to cause reflux in some infants. Please refer to our sections on colic and food intolerance respectively for further information.

Frequent sore throats, hoarse voice, gagging, choking, constantly running nose, sinus or ear infections.

These symptoms may occur if the baby's stomach contents enter the nose, throat or ear canal, due to regurgitation.

Drooling, bad breath, or tooth enamel erosion

The above symptoms can vary in their severity with the infant going through quite "normal" phases where the problem appears to be improving and then re-occurring quite suddenly for no apparent reason. They can also be worsened, or triggered by some medical conditions, such as teething, or a virus etc. However, in general the symptoms tend to improve at six months when the infant becomes more upright, and again at twelve months when the infant becomes mobile.

The vast majority of cases of reflux in infants are due to an incoordination of the upper intestinal tract, which improves as the child gets older and their overall coordination improves, and no treatment is required. However if you are concerned in any way, please seek medical advice. For other children who are distressed, management strategies or treatment may be required