Infant Regurgitation

Infant regurgitation is effortless return of previously swallowed milk into the mouth, with or without visible expulsion, in an otherwise well infant. Diagnostic criteria: in an infant aged 3 weeks to 12 months who is otherwise healthy, two or more regurgitations per day for at least 3 weeks, without retching, haematemesis, aspiration, apnoea, failure to thrive, feeding difficulty or swallowing problems, or abnormal posturing.

• Prevalence about 50 percent at 0 to 3 months, peaking at 4 months at about 67 percent, then declining to under 5 percent by 12 months.
• Mechanism: transient lower oesophageal sphincter relaxation, small stomach capacity, high milk volume intake, liquid diet, low sphincter pressure, delayed gastric emptying and supine posture. It is not due to infection, allergy or obstruction in most.
• Happy spitter: regurgitates large volumes but is comfortable and gains weight normally.
• Complications are uncommon: rarely oesophagitis, aspiration, failure to thrive.
• Parental anxiety and unnecessary treatment are the main harms.

• Frequent spit ups, usually after feeds, effortless, no forceful ejection; infant feeds well, is content, with normal wet nappies and weight gain.
• Examination: normal; weight and length gain along centiles.
• Red flags: forceful or projectile vomiting, bile stained or bloody vomit, onset after 6 months, persistence beyond 18 months, weight loss, refusal to feed, irritability and back arching, abdominal distension, constipation or diarrhoea, blood in stool, apnoea, respiratory symptoms, fever, lethargy, neurological abnormalities, dehydration.

• Clinical diagnosis. Document feeding volumes, frequency, formula preparation, technique and growth.
• Investigations only for red flags or non-response: urine culture and urinalysis (urinary tract infection), electrolytes and gas (pyloric stenosis, adrenal disease, metabolic disease), abdominal ultrasound (pyloric stenosis), contrast study (malrotation, stricture), stool for blood, allergy tests or a supervised elimination course for cow's milk protein.
• Differentials: gastro oesophageal reflux disease, cow's milk protein allergy, pyloric stenosis, infection (urinary tract, sepsis, meningitis, gastroenteritis), malrotation with volvulus, intussusception, raised intracranial pressure, metabolic disease, overfeeding, rumination.

• Reassurance with an explanation of the course; no medication.
• Feeding: ensure correct formula dilution (one level scoop per 30 mL water), avoid overfeeding, offer smaller more frequent feeds, burp during and after feeds, hold upright 20 to 30 minutes, avoid vigorous play after feeds, slow flow teats, address feeding technique and positioning in breastfed infants.
• Thickened feeds: anti-regurgitation formula containing locust bean gum, carob bean gum or starch; thickener powder added to expressed breast milk (carob bean gum, with pre-term infant caution); expect reduced visible regurgitation in 1 to 2 weeks; do not combine multiple thickeners.
• Sleeping: back to sleep; no propping or sleep positioners.
• For suspected cow's milk protein allergy: elimination for 2 to 4 weeks (mother's diet if breastfed, or extensively hydrolysed formula).
• Acid suppression is not indicated for regurgitation.
• Follow up when parents are anxious; review weight at 2 to 4 weeks; plan a review at 9 to 12 months. Refer if symptoms persist beyond 12 to 18 months, weight faltering, red flags.