Reflux & Regurgitation

Regurgitation, also known as posseting or spitting-up is the back-flow of milk from the stomach into the mouth, which is often ‘spat out’ or “dribbles out” of the mouth (NHS, 2020).

Reflux is the involuntary regurgitation or “brining up” of gastric contents after feeding, and occurs in about 20-25% of healthy infants (Davies I et al 2015; Heine 2015).

Reflux and regurgitation are more passive and not the same as vomiting, which is when milk is forced out of the baby’s stomach (NHS Choices Reflux 2023).

Both reflux and regurgitation symptoms are common in infants, and generally resolve by 12 months of age (NHS Choices Reflux 2023). And although they may be unsettling to witness, they are both normal processes that can occur due to physiological immaturity of the lower esophageal sphincter.

Reflux and Regurgitation & CMPA

What causes reflux or regurgitation in infants?

In rare cases there may be an underlying cause to excessive reflux or regurgitation.

For example, gastroesophageal reflux disease (GERD), where the muscle valve between the esophagus and stomach is weak and fails to function correctly, or there is a blockage in the digestive tract.

GERD

Gastroesophageal reflux disease (GERD) is a chronic gastrointestinal disorder characterized by the regurgitation of gastric contents into the esophagus (Antunes et al., 2023). It differs from reflux, in that is causes ‘’troublesome symptoms or complications’’ (Vandenplas et al 2009; Rosen et al 2018) and it can lead to growth faltering (Balgowan et al 2015;Heine et al 2015).

GERD and eosinophilic esophagitis have substantial overlap - both having eosinophils in the esophagus (Simon et al 2016). Therefore, the exact prevalence of GERD in infants is difficult to define because symptoms are not specific (Salvatore et al 2021).

Risk factors for GERD include immaturity of the lower oesophageal sphincter, chronic relaxation of the sphincter, increased abdominal pressure, gastric distension, hiatus hernia, oesophageal dysmotility and food allergy (Kumar Y & Sarvananthan R. 2008; Salvatore et al 2021).

Could it be a symptom of Cow’s Milk Protein Allergy?

CMPA and reflux are considered to be among the most common disturbances seen in infants (Iacono et al 1996; Cavatai eet al 2000). Reflux and regurgitation are also known to be common symptoms of CMPA (Cavatai et al 2000; Salvatore & Vandenplas 2002; Ravelli et al 2001). Cow’s milk protein has been shown to be responsible for inducing symptoms of reflux in almost 50% of infants under the age of 12 months (Iacono et al 1996; Cavatai eet al 2000; Salvatore & Vandenplas 2002). While CMPA has been reported in 16–56% of cases with persistent gastrointestinal symptoms and suspicion of GERD (Salvatore et al 2021).

However, when considering the diagnosis of CMPA, it’s important to consider that the majority of infants with CMPA have at least two symptoms affecting at least two different organ systems (Lifschitz C. and Szajewska H 2015; Host & Halken 1990; Host et al 1994). Therefore, it is important to consider the holistic approach and consider all the infant’s symptoms as well as the severity. This can be achieved using an awareness tool such as the Cow’s Milk Related Symptom Score (CoMiSS®) which will help you determine if CMPA might be indicated (Vandenplas et al 2015;Vandenplas et al 2022).