Feeding challenges

Regurgitation and reflux

Regurgitation and reflux are benign and self-limiting functional gastrointestinal disorders that often occur interconnected. Both are common and normal physiological processes that usually resolve over time and need no intervention. Nevertheless, symptoms can stress parents and lead to decreased quality of life, making therapy with conservative interventions necessary.


Gastro-oesophageal reflux (GOR, also called gastroesophageal reflux GER) describes the involuntary movement of stomach content into the oesophagus. It does not necessarily result in regurgitation, which is the re-entry of stomach content into the oral pharynx or mouth (i.e. spitting-up) (Vandenplas et al., 2009, Benninga et al., 2016). If regurgitation or GOR cause troublesome symptoms (e.g. complications, tissue damage or inflammation), it is classified as gastroesophageal reflux disease (GORD/GERD) (Benninga et al., 2016, Zeevenhooven et al., 2017, Vandenplas et al., 2009).

Rome IV criteria

According to the Rome criteria, infant regurgitation is diagnosed if both of the following criteria are displayed in otherwise healthy infants between three weeks and 12 months (Benninga et al., 2016):

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


GOR and regurgitation are frequent and normal physiological processes most commonly caused by a temporary relaxation of the lower oesophageal sphincter resulting from distention after feeding (Baird et al., 2015). GOR can also occur because of increased intraabdominal pressure following delayed gastric emptying (Leung & Hon, 2019) About 50% of healthy infants younger than three months regurgitate at least once per day, making it the most common functional gastrointestinal disorder (FGID) () in infants below 12 months of age (Baird et al., 2015, Benninga et al., 2016). Preterm infants are particularly affected because of the immaturity of their lower oesophageal sphincter, uncoordinated oesophageal and intestinal peristalsis, slow(er) gastric emptying times and high milk intake in relation to stomach size. Regurgitation occurs in nearly all cases of GOR and is usually harmless. As long as the infant thrives and has no other symptoms it is considered a "happy spitter" (Leung & Hon, 2019).

Management options

Even though regurgitation and GOR are benign and self-limiting disorders, parents are often anxious and stress over the symptoms, which leads to a decrease in quality of their life. In general, no treatment is necessary but parents' concerns should be addressed and reassured (Leung & Hon, 2019, Benninga et al., 2016). If regurgitation occurs often or becomes problematic, several management options are available:

Dietary options

  • Continuation of breastfeeding should be encouraged (Salvatore et al., 2018a, Leung & Hon, 2019).
  • Amount, frequency, behaviour during the feeding (choking, coughing, refusal, etc.) or formula preparation, if applicable, should be evaluated and adapted if necessary (Vandenplas et al., 2009). Any formula should always be prepared according to the manufacturer's instructions (on the label) and fed in age and weight appropriate volumes, which are also stated on the label (WHO, 2009). Deviations from the preparation instructions can affect viscosity and influence feedings negatively, as for example formula with high viscosity can reduce the intake volume because of the required increased sucking effort (September et al., 2014).
  • Addition of thickening agents (e.g. starch, carob/ locus bean gum, and others) to expressed breast milk or infant formulas alike can be considered carefully. These additives can decrease regurgitation but bear the risk of over-thickening that can likewise increase viscosity to an extend that higher sucking efforts are necessary. This often encourages the caregiver to enlarge bottle teats, which unnecessarily increases volume intake (Salvatore et al., 2018b, Benninga et al., 2016). Thickening with starch changes energy density of the product and can thus result in excessive energy intake and exaggerated weight gain (Vandenplas et al., 2009). Therefore, self-thickening should be treated with caution.
  • For formula-fed infants, use of commercially available thickened formulas - sometimes called "anti-regurgitation formulas" - with thickening ingredients such as starch or carob/ locus bean gum, etc. can be considered. These formulas avoid the risk of over-thickening are available on many markets (Salvatore et al., 2018b, Leung & Hon, 2019). Commercially available anti-regurgitation formulas, if prepared correctly, have an adequate energy density, viscosity, protein and fatty acid content to meet the infant's needs, whereas self-thickened formulas may exceed these needs (Vandenplas et al., 2009).
  • Lower feeding volumes together with smaller and more frequent feeds could be suggested to alleviate symptoms when overfeeding is indicated (Salvatore et al., 2018a, Leung & Hon, 2019) because overfeeding worsens regurgitation (Vandenplas et al., 2009). Caregivers should therefore be advised to feed ad libitum, pay attention to the infant's feeding cues and stop feeding when the child indicates that it is satiated to avoid overfeeding. Indicators for satiation include slower suckling, often with fewer suckles and longer pauses in between, spitting out of the nipple or teat, a content facial expression and pushing backwards (WHO, 2009).​​​


Changes in posture

Upright positioning after feeding helps to decrease regurgitation frequency, but should not be carried out in unattended or sleeping infants (Leung & Hon, 2019).

Lifestyle changes

Breastfeeding is recommended because breastfed infants are less likely to exhibit GOR. Breastfeeding mothers can try a low allergenic diet (e.g. avoidance of cow's milk) when intolerance or allergic reactions are suspected, whereas for formula-fed infants hydrolysed protein formulas can be tested. Other recommendations include weight reduction in overweight infants and avoidance of overfeeding (Leung & Hon, 2019, Baird et al., 2015, Benninga et al., 2016).


Usually pharmacological treatment is unnecessary because GOR most often resolves itself within the first 12 month of life. If infants display GORD, which does not resolve with conservative (non-pharmacological) measures, pharmacological options (e.g. H2-receptor antagonists and proton pump inhibitors) are available (Leung & Hon, 2019, Baird et al., 2015, Benninga et al., 2016).