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NICE guidance on managing frequent infant regurgitation

5 mins
Mother and baby


Feeding issues, also known as functional gastrointestinal disorders (FGIDs) are a common part of life for infants2 and can have a considerable impact on both the infant and parents.

As parents try to navigate through this confusing time, they may try a variety of options, research feeding issues online and visit their GP several times in order to find a solution, impacting on the time and resources of healthcare professionals.3

Gastro-oesophageal reflux and effortless regurgitation in infants is common and affects at least 40% of infants1

If there are no other symptoms and the baby is growing well and seems happy, parents should be reassured and supported to take steps that may help, as outlined below.

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Managing infant regurgitation

To manage frequent regurgitation associated with marked distress in breastfed infants, NICE guidelines recommends that a healthcare professional with appropriate expertise and training should carry out a breastfeeding assessment first-line.1

To manage frequent regurgitation associated with marked distress in formula-fed infants, NICE recommend this stepped care approach1 as shown below:

  1. Review the feeding history and reduce feed volumes if excessive for infant’s weight.
  2. Advice to trial smaller volumes of more frequent feeds (while maintaining the appropriate daily volume of milk)
  3. Advice to trial a thickened formula e.g. containing starch thickener††
  4. If the stepped care approach is unsuccessful, stop using the thickened formula and trial alginate therapy for 1 – 2 weeks
  5. If alginate therapy is successful, continue use but stop periodically to assess recovery

SMA ® Anti-Reflux is a thickened formula for the dietary management of reflux and regurgitation, it is suitable from birth until 1 year of age and shown to significantly reduce the number of daily regurgitation episodes4**.

It is a suitable thickened formula for managing regurgitation as recommended by the NICE stepped care approach.1

SMA Anti-Reflux

SMA ® Anti-Reflux is the only anti-reflux formula in the UK&I with a unique combination of easily digestible starch and 100% whey, partially hydrolysed protein, to help manage reflux and regurgitation4,5

Digestible starch thickeners do not interfere with the availability of calcium, iron and zinc compared to indigestible thickeners, such as Carob bean gum6,7

* Associated with marked distress
Thickened formulas may require a fast flow teat
††Not all thickened formulas are the same, consider one which also contains partially hydrolysed proteins which allows for faster gastric emptying.8
**p<0.0001, compared to a standard formula

Related articles

  1. NICE (2015). Gastro-oesophageal reflux disease in children and young people. Available at Accessed: May 2020.

  2. Iacono G et al. Dig Liver Dis 2005; 37: 432–438.

  3. Incite, Feeding issues journey 2019.

  4. Indrio F, et al. Nutrients 2017, 9 , 1181.

  5. SMA® Anti-Reflux datacard (2020). Available at

  6. D. Bosscher, M. Van Caillie-bertrand & H. Deelstra (2003) Do thickening properties of locust bean gum affect the amount of calcium, iron and zinc available for absorption from infant formula? In vitro studies, International Journal of Food Sciences and Nutrition, 54:4, 261-268.

  7. Bosscher et al. Thickening Infant Formula With Digestible and Indigestible Carbohydrate: Availability of Calcium, Iron, and Zinc In Vitro. Journal of Pediatric Gastroenterology & Nutrition: April 2000 - Volume 30 - Issue 4 - pp 373-378.

  8. Billeaud C et al. Eur J Clin Nutr 1990; 44: 577–583.


The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use a formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. This product must be used under medical supervision. SMA® Anti-Reflux is a special formula intended for the dietary management of bottle-fed babies when significant reflux (regurgitation) is a problem. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 12 months of age. If the baby’s reflux does not improve within 2 weeks of starting SMA® Anti-Reflux, or if the baby fails to thrive, the family doctor should be consulted