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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Physiological GOR (possetting/regurgitation): affects 40–60% of infants, peaks at 4 months, resolves by 12–18 months in >90%
- GORD: GOR with complications — faltering growth, oesophagitis (irritability, back-arching, feed refusal), respiratory symptoms (wheeze, recurrent aspiration)
- Red flags: bilious vomiting (malrotation), projectile vomiting at 2–8 weeks (pyloric stenosis), blood in vomit/stool (CMPA or oesophagitis), onset after 6 months or persisting beyond 12 months
- Management: positioning (head up), smaller frequent feeds, thickened feeds or alginate (Gaviscon Infant). PPI (omeprazole) ONLY for proven oesophagitis or clear GORD not responding to conservative measures
- 2–4 week trial of CMPA exclusion (hydrolysed formula or maternal dairy exclusion if breastfed) if suspected
- Most infants DO NOT need medication — reassurance and feeding advice is the mainstay
Overview
Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is physiological in infants due to a short oesophagus, predominantly liquid diet, and immature lower oesophageal sphincter. GOR is distinguished from gastro-oesophageal reflux disease (GORD) by the presence of complications. The vast majority of infant reflux resolves spontaneously by 12–18 months as the child weans onto solids, spends more time upright, and the lower oesophageal sphincter matures.
Epidemiology
GOR affects 40–60% of infants at some point, with peak symptoms at 4 months. By 12 months, symptoms resolve in over 90%. Only a minority have true GORD requiring treatment. Risk factors for GORD include prematurity, neurological impairment, congenital diaphragmatic hernia, oesophageal atresia (post-repair), and obesity. CMPA is an important differential and coexists with GORD.
Clinical Features
Symptoms
Frequent regurgitation (possetting) — effortless, painless, small volumes after feeds
Excessive crying, irritability, back-arching during or after feeds (Sandifer syndrome)
Feed refusal or poor feeding
Faltering growth (suggests GORD, not simple GOR)
Projectile vomiting at 2–8 weeks (think pyloric stenosis)
Bilious (green) vomiting (think malrotation — surgical emergency)
Blood in vomit or stool (oesophagitis or CMPA)
Signs
Well, thriving infant despite frequent regurgitation (happy spitter = GOR, not GORD)
Weight faltering on growth chart
Respiratory signs: wheeze, chronic cough, recurrent aspiration pneumonia
Investigations
First-line
Clinical diagnosisNo investigations needed for uncomplicated GOR in a thriving infant. Diagnosis is clinical
Second-line
2–4 week CMPA exclusion trialSwitch to extensively hydrolysed formula (or maternal dairy-free diet if breastfed) — if symptoms improve, CMPA is the diagnosis
Blood gas and electrolytesIf vomiting is forceful or persistent — exclude pyloric stenosis (hypochloraemic alkalosis)
Specialist
Upper GI endoscopyIf suspected oesophagitis not responding to treatment, or haematemesis
24-hour pH/impedance studyGold standard for quantifying reflux — rarely needed in infants
1
Reassurance and positioning (first-line for GOR)
- Reassure: GOR in a thriving infant is normal and self-limiting
- Smaller, more frequent feeds
- Keep upright for 30 minutes after feeds
- Raise head of cot slightly
- Continue breastfeeding — do not stop. Breastfed infants have less severe reflux
2
Thickeners and alginates
- Thickened feeds: pre-thickened formula or add thickener (Carobel) to expressed breast milk
- Alginate (Gaviscon Infant): forms a raft on stomach contents — give after feeds
- Not recommended to use Gaviscon AND thickened feeds together
3
CMPA exclusion
- 2–4 week trial of extensively hydrolysed formula (or maternal dairy-free diet if breastfed)
- If symptoms improve: CMPA confirmed, continue exclusion. Dietetic referral
- If no improvement: reintroduce cow milk, consider other diagnoses
4
PPI therapy
- Omeprazole only for proven or suspected oesophagitis (irritability, feed refusal, haematemesis)
- 4-week trial of omeprazole (1 mg/kg/day)
- Review and attempt to stop after 4 weeks
- Do NOT prescribe routinely for uncomplicated GOR
Complications
- Oesophagitis: Erosive or non-erosive — causes pain, feed refusal, haematemesis
- Faltering growth: If GORD causes significant feed refusal or vomiting
- Aspiration: Recurrent aspiration pneumonia in severe cases (especially neurologically impaired children)
- Sandifer syndrome: Dystonic posturing (back arching, head turning) associated with GOR — resolves when reflux treated
UKMLA Exam Tips
- 1Happy spitter = thriving infant with frequent possetting = physiological GOR. No treatment needed beyond reassurance
- 2GORD = reflux + complications (faltering growth, oesophagitis, respiratory). Only GORD needs treatment
- 3Always consider CMPA in infants with reflux symptoms — 2–4 week exclusion trial
- 4PPIs are NOT first-line for uncomplicated reflux — positioning, smaller feeds, alginates first
- 5Bilious vomiting = malrotation until proven otherwise — surgical emergency
- 6Projectile vomiting at 2–8 weeks = pyloric stenosis — USS and surgical referral
- 7Sandifer syndrome: back arching + head turning in an infant with GOR — NOT a seizure
practicetest your knowledge on gor in infantsApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — paediatrics and beyond.
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