Reflux & Regurgitation – Causes, Diagnosis and Guidelines

Reflux or gastro oesophageal reflux (GOR) occurs when the stomach contents leak back into the oesophagus after feeding, with or without regurgitation and vomiting. GOR is a normal physiologic process occurring several times per day in healthy infants, children, and adults1.

Regurgitation (also known as spitting up/posseting) is the word used to describe what happens when the stomach contents come back up into the pharynx or into the mouth1. Regurgitation is common during the first year of life, affecting 30% of infants2. It normally peaks at four months of age and starts to decrease at seven months and usually resolves at 12 months.


Reflux and regurgitation are considered normal physiological processes that occur several times a day in healthy infants. They are caused by the valve at the top of the stomach having a weak action. Food and stomach acid can move back into the oesophagus.1


  • Regurgitation
  • Excessive crying / irritability during/after feeding
  • Regular coughing
  • Arching of neck and back during or after feeding
  • Poor sleep habits typically with frequent waking

ROME IV criteria for the diagnosis of infant regurgitation4

Must include both the following in otherwise healthy infants, aged 3 weeks to 12 months old:

  • Regurgitation 2 or more times per day for 3 or more weeks.
  • No retching, haematemesis, aspiration, apnoea, failure to thrive, feeding or swallowing difficulties or abnormal posturing.

NEW: ESPGHAN Reflux Guidelines5

New 2018 ESPGHAN clinical guidelines for the diagnosis and management of reflux in infants and children, intended to be applied in daily practice

The guidance states:

  • No indication for the usage of proton pump inhibitors, prokinetic drugs, or H2 antagonists in so called uncomplicated regurgitation or GOR/GER.
  • No indication for the usage of antacids/alginates in chronic GOR/GER
  • No indication for the usage of positional therapy to treat symptoms of GOR/GER in sleeping infants

Practical Management3

  • Parental reassurance – first and foremost, parents need support
  • If the infant is bottle fed, check the hole in the teat is not too large
  • Wind the infant before, during and after feeds
  • Avoid overfeeding – try feeding smaller amounts more frequently
  • Feed the infant in an upright position
  • Avoid clothing that is too tight around the infant’s tummy
  • Encourage placing the infant in an upright position after milk feeds.


Nutritional solutions for bottle-fed infants

Thickened anti-reflux formula, e.g. Aptamil Anti-Reflux



  1. Lightdale J et al., Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013; 131 (5):e1684-e1695
  2. Vandenplas Y et al ,J Pediatr Gastroenterol Nutr 2015; Nov 61(5):531-710.
  3. Vandenplas J et al. J Pediatr Gastroenterol Nutr 2009;49:498-547
  4. Benninga MA. et al., 2016; 150:1443-1455.
  5. Rosen R. et al., Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66(3) 516-554