Reflux in babies means that stomach contents come back up the food pipe and often out through the mouth. It is very common in the first six months, tends to be at its worst at around four months and goes away by itself in most babies before the age of one. A baby who brings up milk but is gaining weight and content needs no treatment.
It is half past two on a Wednesday in a flat on Södermalm. A ten-week-old baby has just fed, fallen asleep on a shoulder, and then it comes: a splash of lukewarm milk down the back of the jumper, the third that day. Is it normal? Usually, yes. Here is how to tell ordinary spit-up from reflux that needs medical attention, and what actually makes a difference day to day.
Spit-up or reflux: what is the difference?
When a baby brings up a little milk after a feed it is often called vomiting, but it is rarely true vomiting. The muscle between the food pipe and the stomach is still weak, the stomach is small and the baby lies down for much of the day. So it flows back up. This is physiological reflux, and most babies have it to some degree. It is normal, and it is not dangerous.
Reflux disease is when the spit-up causes problems: the baby is in pain, refuses to feed, fails to gain weight or has trouble breathing. It is uncommon, but it is the kind the healthcare system wants to hear about. The difference, then, lies not in how much comes up but in how the baby is doing.
Signs of reflux in babies
- Brings up milk after most feeds, sometimes only half an hour later
- Cries during or after feeds, arches the back, bends backwards
- Wants to feed often but stops after a few sucks
- Hiccups and burps a lot, grimaces and swallows afterwards
- Is clearly happier upright than lying down
- Coughs or clears the throat after feeds
- Sleeps restlessly on the back, wakes up whimpering shortly after being put down
Crying, hiccups and an arched back are also things perfectly healthy babies do, especially between three weeks and three months. It is the pattern that counts: does the trouble almost always come with feeds, and can you see that your baby is in pain? Then it is worth a conversation with BVC (the child health clinic every family is enrolled in).
How much is normal, month by month
| Age | Typical picture |
|---|---|
| 0 to 3 months | Spit-up several times a day, small amounts, baby content and gaining weight |
| 4 to 6 months | Often the peak. Many babies bring up milk after almost every feed |
| 6 to 9 months | Decreases as the baby sits up more and starts on solids |
| 9 to 12 months | Most have stopped or spit up only occasionally |
| 12 to 18 months | Almost all have stopped. Ongoing trouble should be looked at by BVC |
What helps, in practice
- Smaller feeds, more often. An overfull stomach overflows. Better seven small feeds than four big ones.
- Burp halfway through and afterwards. Switch sides or pause the bottle halfway, hold your baby upright against your shoulder.
- Upright for half an hour after feeds. In a carrier, against your shoulder, or sitting on your lap. Not lying in a bouncer, which presses on the stomach.
- Calm feeding. A baby screaming with hunger swallows air. Catch the early cues.
- The right teat hole for bottles. Too big a hole and the milk flows too fast; too small and the baby swallows air. Hold the bottle so the teat is full of milk.
- No pressure on the tummy. A loose nappy after feeds, no long stretches in the car seat straight after a meal.
- Tummy time when your baby is awake. It strengthens the muscles, but wait a while after feeds.
Do not raise the head end of the cot and do not put anything under the mattress. Babies should sleep flat on their back; that is the advice for reducing the risk of sudden infant death, and it outweighs the reflux. Thickened formula, special formula or acid-reducing medicines are not something to try on your own. Raise it with BVC or a doctor, who can assess whether it is needed. For the vast majority it is not.
Reflux or cow's milk allergy?
Sometimes it is not reflux. An allergy to cow's milk protein often gives a similar picture: crying, spit-up and poor weight gain, but in addition eczema, mucus or blood in the stool and loose bowel movements. If you are breastfeeding, your baby may react to milk protein that passes into breast milk. Do not test it yourself by switching formula back and forth or cutting milk from your own diet at random. Raise it with BVC, who can assess it and refer you if needed. A wrong self-diagnosis costs weeks of unnecessary worry and sometimes poorer nutrition.
When to seek care
| Call BVC or 1177 | Wait and ease it at home |
|---|---|
| Baby is not gaining weight, or is losing it | Spits up but follows their curve at BVC |
| Projectile vomiting that gets more forceful week by week | Small amounts of spit-up that dribble out |
| Green or bloody vomit, or blood in the poo | White or yellowish milk, sometimes a little curdled |
| Baby refuses to feed or screams at every feed | Feeds, grizzles a little, falls asleep content |
| Coughing, wheezing, pauses in breathing | Hiccups and burps |
| Trouble that only starts after six months or continues past 18 months | Clearly decreasing after six months |
Projectile vomiting in a baby who is a few weeks old and getting hungrier and hungrier should be assessed the same day; call 1177 (the national healthcare helpline). It may be a narrowing at the outlet of the stomach, pyloric stenosis, which needs surgery. It is uncommon and easy to treat once found, but it does need to be found.
Laundry, clothes and patience
Anyone with a reflux baby learns fast: a bib all day, a towel over the shoulder, a spare bodysuit in the bag, a terry towel in the pram and a sheet that can be changed in two minutes. It sounds trivial, but it is what keeps you going. And it passes. Reflux is one of the few baby worries where time really does solve most of it, without you having to do anything particularly right.
How we do it with our families
Doaa looks after a family in Sundbyberg with a five-month-old who brings up milk after every feed. She gives the bottle calmly in the quiet room, pauses halfway for a burp, and then the baby sits in a carrier on her while she tidies the kitchen for half an hour before the nap. On her note she writes how much the baby has eaten and whether anything was different: more than usual, seemed to be in pain, coughed. The parents take the note with them to BVC. Because she comes on the same days every week, she can say when it has got better, and it does.
This text is general information and does not replace advice from BVC, your vårdcentral (local health centre) or 1177. If you are worried about your child, call 1177. In an emergency, call 112.
Would you like a nanny who knows your child, knows what is normal for them and notices when something is different? Book a free first meeting with the nanny in your home.
Read more: Colic in babies · Newborn · Evening fussiness in babies · FAQ
Frequently asked questions
How do I know whether it is reflux or just ordinary spit-up?
Ordinary spit-up dribbles out without the baby minding, and the baby gains weight and is content between feeds. Reflux that needs care causes pain: screaming at feeds, an arched back, refusing to feed, poor weight gain or coughing and breathing trouble. It is the pattern over weeks that counts, not a single day.
Does it help to lay the baby with the head raised?
No, and it is advised against. Babies should sleep flat on their back; that is the advice for reducing the risk of sudden infant death and it comes before the reflux. What does help is holding your baby upright against your shoulder or in a carrier for half an hour after feeds, while the baby is awake.
Can I give thickened formula or välling for reflux?
Not on your own. Thickened formula exists and is sometimes used, but it should be assessed by BVC or a doctor first, because the trouble may be due to something else, such as cow's milk allergy. Call BVC and describe what you are seeing, and you will get the right advice for your baby.
When does reflux go away?
It is usually at its worst at four to six months and then decreases as the baby sits up more, eats more solid food and the muscles mature. The vast majority have stopped spitting up before the age of one. If it continues past 18 months, or only starts after six months, BVC should take a look.
Should a baby with reflux sleep on their tummy?
No. Lying on the tummy does reduce spit-up slightly, but it increases the risk of sudden infant death, and that outweighs it. Put your baby down on their back. Tummy time is good when your baby is awake and you are there, but not straight after feeds.