Gastro Oesophageal Reflux and ‘silent reflux’ in Babies
In our London Allergy Consultants clinics, we see many patients who attend for assessment of an allergic cause for their infants’ GOR. Many of these children (and their breastfeeding mothers) are already on dietary interventions and antacid medications. Their parents are often exhausted and desperate for a rapid intervention; however, the best approach to management varies in each clinical scenario and requires a detailed interactive assessment.
There is considerable controversy amongst experts in the field regarding how best to manage GOR. This blog aims to reassure families and provide evidence-based advice, and seeks to caution regarding the overuse of antacids and elimination diets.
The recommended management of gastro-oesophageal reflux (GOR) in babies according to both United Kingdom (NICE) and European (ESPGHAN) guidelines is primarily conservative and supportive.
Both guidelines emphasise that GOR is a physiological process in infancy and usually resolves spontaneously by 12 months of age.
It is essential to recognise that common infant symptoms such as regurgitation, colic, and eczema are much more prevalent than cow's milk protein allergy, and most infants with these symptoms do not have the allergy.
Conservative approaches are first-line and include parental reassurance, education, and avoidance of overfeeding. Both guidelines recommend smaller, more frequent feeds and holding the infant upright after feeding.
Feed thickening (e.g., with rice cereal or commercial thickeners) is suggested for formula-fed infants with persistent regurgitation, as it can reduce visible vomiting episodes. However, it does not alter acid exposure. In our experience, such thickeners may cause constipation.
Dietary management is similar in both guidelines. For formula-fed infants with ongoing symptoms despite optimal conservative measures, a 2–4 week trial of extensively hydrolysed or amino acid-based formula is recommended to address possible cow’s milk protein ‘allergy’. For breastfed infants, maternal elimination of cow’s milk protein may be considered, as long as the maternal diet remains nutritionally complete. These interventions should, however, be a last resort, as the evidence base to support them is weak and their cost, taste, biome, formula access, and other implications are significant.
Pharmacological therapy is reserved for infants with severe, persistent symptoms or complications after non-pharmacological and dietary interventions have failed and where acid may be contributing to oesophageal function, or baby’s pain. Both guidelines recommend that acid-suppressing medications (H₂ antagonists, PPIs) should not be used for uncomplicated GOR, as randomised trials show no clear benefit and potential for harm.
However, if medication is considered, it should be for infants with confirmed gastro-oesophageal reflux disease (GORD) and only after other measures have failed, as it is physiologically normal for humans to have acid in their stomachs, facilitating food digestion and sterilisation as well as facilitating a healthy gut biome. It is important to note that antacid medications (proton pump inhibitors and H₂-receptor antagonists) are associated with an increased risk of developing food allergies in infants and children.
Positional therapy (prone or lateral positioning) is not recommended for sleeping infants due to the risk of sudden infant death syndrome.
In summary, conservative and dietary management are the mainstays of care for GOR in babies in both UK and European guidelines, with pharmacological therapy reserved for select cases with severe disease. There are no major differences between UK and European recommendations
Frequently Asked Questions
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Silent reflux is not a formal or recognized medical term in the pediatric gastroenterology literature. The correct terminology is gastroesophageal reflux (GOR), which refers to the passage of gastric contents into the esophagus, and gastroesophageal reflux disease (GORD), which is GOR associated with troublesome symptoms or complications.
In infants, GOR is extremely common and often physiologic, occurring with or without visible symptoms such as regurgitation or vomiting; many infants experience episodes that are asymptomatic, sometimes referred to informally as "silent" reflux.
Objective measurement using pH-multichannel intraluminal impedance (pH-MII) demonstrates that both acid and non-acid (often called "silent" or "nonacid") reflux episodes occur frequently in infants, with the majority of refluxate being nonacidic due to frequent feeding.These episodes may not produce overt symptoms like regurgitation, but can still be detected instrumentally. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recognize that reflux episodes in infants can be asymptomatic and that nonacid reflux constitutes a significant proportion of total reflux events.
In summary, asymptomatic (or "silent") gastroesophageal reflux does exist in infants, and is considered a normal physiologic process. The term "silent reflux" is not used in guidelines or formal literature, but the phenomenon of asymptomatic reflux is well described and supported by objective diagnostic studies
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Yes, antacid medications (proton pump inhibitors and H₂-receptor antagonists) are associated with an increased risk of developing food allergies in infants and children.
Multiple large cohort studies and meta-analyses from the United States and Europe demonstrate a consistent association between acid-suppressive medication use in infancy and subsequent diagnosis of food allergy, with adjusted hazard ratios for food allergy ranging from 1.28 to 2.59 depending on the drug class and duration of exposure.
The risk appears to be dose-dependent, with longer duration of therapy conferring greater risk.
The mechanism is thought to involve impaired protein digestion and altered gut microbiota, leading to increased sensitization to dietary antigens. This association persists even after adjusting for confounding factors such as indication for treatment (e.g., GORD) and antibiotic use.
Current guidance from both the United States and European authorities, including the European Society of Pediatric Allergy and Immunology, is to use acid-suppressive medications judiciously in infants and children, reserving them for clear indications and for the shortest effective duration, due to these potential risks.
The National Institute for Health and Care Excellence (NICE) in the UK and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition also recommend against routine use of acid-suppressive medications for uncomplicated gastro-oesophageal reflux in infants, reflecting concern about adverse effects including allergy risk.
In summary, the use of antacid medications in infancy is associated with an increased risk of food allergy, and current US and European guidance recommends restricting their use to infants with clear indications.[1-5]
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Cow's milk protein allergy should be suspected in infants who present with reproducible symptoms following exposure to cow's milk protein, either through formula, dairy-containing foods, or breast milk.
For IgE-mediated allergy, suspicion arises when infants develop immediate-onset symptoms (within 2 hours of ingestion), such as vomiting, urticaria, angioedema, erythema, respiratory distress, or lethargy. These symptoms typically resolve within hours and recur reliably with re-exposure.
Non-IgE-mediated cow's milk protein allergy should be considered in infants with delayed-onset gastrointestinal symptoms, including persistent vomiting, diarrhea, blood in stools (especially in otherwise well-appearing neonates), chronic cutaneous symptoms, failure to thrive, or unexplained crying and irritability. In breastfed infants, symptoms may also occur due to transfer of cow's milk protein via breast milk.Notably, blood in the stool is a classic presentation in neonates and young infants, and eosinophilia may be present.
It is important to recognize that common infant symptoms such as regurgitation, colic, and eczema are much more prevalent than cow's milk protein allergy, and most infants with these symptoms do not have the allergy. Therefore, suspicion should be heightened when symptoms are persistent, severe, reproducible with cow's milk exposure, and not explained by other common conditions such as gastroesophageal reflux or infection.
Diagnosis is clinical, supported by history, and may be aided by skin prick testing or specific IgE measurement for IgE-mediated cases, and by elimination and oral food challenge for non-IgE-mediated cases.
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In the UK, "feed thickeners" most commonly refer to products used to manage infant reflux and regurgitation. These are either pre-thickened formulas or thickening agents that are added to breast milk or standard infant formula.
The use of these products should always be under the guidance of a healthcare professional especially if a food allergy is suspected.
Common Ingredients and Types
Feed thickeners work by adding a gelling or thickening agent to the liquid. These can lead to constipation. The most common ingredients found in UK products are:
Carob Bean Gum (also known as locust bean gum): This is a natural thickener derived from the carob bean. It is a key ingredient in many anti-reflux formulas and thickening agents. Products containing carob bean gum thicken the liquid in the bottle, helping it to stay down in the baby's stomach.
Starch: Some anti-reflux formulas, like SMA Anti-Reflux, use starch (such as potato or corn starch) as the thickening agent. Starch-thickened formulas are designed to become thicker in the baby's stomach, which can help reduce regurgitation.
Alginate: This is another natural thickening agent often used in products like Gaviscon Infant. It forms a gel-like raft on top of the stomach contents, which helps to prevent reflux.
UK Products and Their Formulations
Popular feed thickeners and thickened formulas available in the UK:
Cow & Gate Instant Carobel: This is a thickening agent that can be added to breast milk, infant formula, or other liquids. Its main ingredients are maltodextrin, carob bean gum, and some minerals. It is a food for special medical purposes and is suitable for use in full-term infants, children, and adults under medical supervision.
Aptamil Anti-Reflux: This is a nutritionally complete, pre-thickened formula. It contains carob bean gum to help manage frequent reflux and regurgitation. Because it is already thickened, it requires a fast-flow teat to be used for feeding.
SMA Anti-Reflux: Another nutritionally complete formula, this product uses a combination of starch and whey protein to manage reflux. Like other anti-reflux formulas, it is thickened and requires a specific method of preparation.
Cow & Gate Anti-Reflux: Similar to Aptamil, this is a thickened formula that uses carob bean gum. It is designed to be a sole source of nutrition from birth and is available over-the-counter but its use should be discussed with a healthcare professional.
Important Considerations for Use
Medical Supervision: All of these products are classified as "foods for special medical purposes" and should only be used under the guidance of a doctor, health visitor, or dietitian. They are not recommended for routine use or for premature infants without medical advice.
Preparation: The preparation instructions for thickened feeds are often different from standard formulas. It is crucial to follow the manufacturer's guidelines precisely to ensure the correct consistency and to avoid health risks. For example, some may need to be shaken and then left to stand to thicken, and many require a specific type of teat (e.g., a single-hole, fast-flow teat).
Not a Sole Source of Nutrition: Thickening agents like Instant Carobel are not a complete food and should only be used in combination with breast milk or formula
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If your child is showing signs of a food, pollen, or skin allergy, early diagnosis is key. At London Allergy Consultants, our expert team provides trusted, evidence-based care tailored to your child’s needs. From testing to treatment plans, we guide you every step of the way.
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