Infant reflux & GORD
When spit-up is normal, when it's gastro-oesophageal reflux disease, and when reflux is actually pointing at something else entirely. A paediatric dietitian's guide to making sense of it.
Reflux versus GORD versus allergy
Almost all babies bring up some milk after feeds. That's simple posseting and it's not a problem. It's messy, it goes through a lot of muslins, and it's completely normal. According to NICE guidelines, reflux becomes gastro-oesophageal reflux disease (GORD) when it's causing significant symptoms: persistent distress during or after feeds, feed refusal, poor weight gain, respiratory symptoms, or a baby who is clearly uncomfortable much of the time.
What I see frequently in clinic is that a meaningful proportion of babies being treated for reflux actually have an underlying cow's milk protein allergy. The symptoms overlap substantially. Vomiting, feed refusal, distress, arching, and unsettled behaviour can all be caused by either reflux or allergy. If reflux treatment isn't working, investigating CMPA is often the most productive next step. This is exactly what I assess in a consultation.
There's also 'silent' reflux, where the baby shows signs of discomfort, arching, and feed aversion without visibly bringing milk up. This can be harder to identify because the most obvious sign, the vomiting, isn't there. But the pattern of distress around feeds, particularly with arching and pulling away, is often the giveaway.
Practical management of reflux
Approaches supported by NICE guidance include reviewing feed volumes and frequency, positioning during and after feeds, and — where there are other suggestive symptoms — considering whether cow's milk protein allergy is playing a role. Which of these is relevant depends on your baby's feeding method, the severity of the reflux, and other factors, which is what a consultation identifies.
When reflux points to allergy
This is something I spend a lot of time discussing with parents. Cow's milk protein allergy can present almost identically to straightforward reflux, and the two conditions can coexist. If your baby has reflux that isn't responding to standard management, or if there are additional features that suggest allergy, such as eczema, blood or mucus in stools, persistent gut symptoms, or a family history of atopy, it's worth investigating CMPA.
The iMAP guideline diagnostic approach for non-IgE CMPA is a structured elimination diet: removing dairy from the maternal diet for breastfed babies, or switching to an extensively hydrolysed formula for formula-fed babies, for a trial period of 2 to 4 weeks. If symptoms improve, a planned reintroduction confirms the diagnosis. This needs to be done properly to give a reliable answer, and a dietetic assessment guides the process.
It's not uncommon for families to manage 'reflux' for months with medication, when a dietary assessment and elimination trial can lead to significant symptom improvement within weeks. It's one of those areas where the right assessment can make a meaningful difference.
Medication and when it's appropriate
Reflux medication has a role when practical measures alone aren't sufficient and when allergy has been considered. As outlined in NICE reflux guidance, Medication options exist and are prescribed by your GP or paediatrician. A dietitian helps determine whether addressing the underlying dietary cause might be more appropriate than relying on medication alone.
What's important to understand is that medication addresses the symptoms rather than the cause. If the reflux is being driven by an underlying allergy, medication may partially improve things but won't resolve the problem. This is why I always advocate for a thorough assessment before assuming medication is the answer. The order should be: practical measures first, consider allergy, then medication, in discussion with your GP or paediatrician, if needed alongside rather than instead of addressing the underlying cause.
The timeline for reflux improvement
Most uncomplicated reflux improves significantly by 12 months as the lower oesophageal sphincter matures and the baby spends more time upright. It often peaks around 4 months and gradually settles from there. By 18 months, the vast majority of babies have outgrown it.
If reflux isn't improving by 12 months, or if it was never straightforward from the beginning, that's a strong signal to reassess. Persistent reflux beyond the expected timeline may indicate an undiagnosed allergy, a structural issue, or another condition that needs investigation. A dietetic and medical review at this point can make sure nothing has been missed.
Common questions
A clear plan,
built around your little one.
All consultations are online and you can self-refer directly. You'll receive a written plan after every appointment.
Thorough assessment & plan
Your first appointment is 60 minutes. It includes a full clinical and dietetic assessment, and you'll receive an agreed, written plan to take away.
Review & adjust
Follow-ups are 30 minutes. We review the plan, problem-solve anything that's come up, and adjust guidance as your child progresses.
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