Burping vs Reflux: What's the Difference?

These get confused constantly, including by me for a good many years, and the confusion has a cost, because the responses are different and one of them is a medical question.

Wind is air going the wrong way, and reflux is milk going the wrong way. Almost everything else follows from that.

Telling them apart

Timing does most of it. Wind is a discrete event with a beginning and an end: she's uncomfortable, something comes up or passes through, and she's better. Reflux is a state and not an event, arriving during feeds as well as after them, and it doesn't resolve with a burp because there's no air to release, however long you pat. I'm not sure I'd have seen the difference with my first. I do now.

The other reliable difference is what she does with her body, and this is the one I'd have you watch for. A baby with wind tends to draw her knees up. A baby with reflux tends to arch backwards and pull away from the feed, which is close to the opposite movement, and once you've seen the two side by side you won't mistake them again.

How common is this, really?

Bringing milk up is close to universal and very seldom a disease.

Around half of all babies regurgitate regularly in the first months, it peaks at about four months, and the large majority have grown out of it by twelve, as the valve at the top of the stomach matures and they spend more of the day upright, and the joint paediatric gastroenterology guidelines are clear that the great majority of this needs no treatment at all beyond reassurance and time, and a great many muslins.

The proportion in whom it becomes reflux disease, causing real harm and not just mess, is small, and that distinction is the whole of the clinical question, and it's the reason doctors ask about weight and distress, and never about volume, whatever the state of your laundry.

Silent reflux, and why it gets missed

Some babies bring milk part of the way up and swallow it again, so there's nothing to see and no washing, and the discomfort is entirely invisible to anybody who's looking for spit-up, which is everybody.

What you see instead is a baby who's distressed at feeds and after them, who arches and pulls away, who swallows repeatedly or makes a gulping sound between feeds, who may have a hoarse cry or a persistent cough, and who's very often described as colicky because nobody has connected it to feeding, and I described one of mine that way for months.

It gets missed for the obvious reason that everybody, including a good many professionals, is looking for the milk. If your baby has the distress without the mess, say so at the appointment in those words, and don't call it unsettledness, because the words you use change what gets considered.

What helps

Almost everything you can do is positional and it costs nothing.

• Smaller feeds, more often, so there's less in the stomach at any moment.
• Upright or laid-back positioning during feeds, and upright for twenty to thirty minutes afterwards.
• Paced bottle feeding, or feeding lying back if your let-down is fast.
• Gentle, brief winding. Firm patting and jiggling both make it worse.
• Nothing pressing on the abdomen, no tight waistbands, no bending her at the hip, no shoulder in her stomach.
• No bouncing or vigorous play immediately after a feed.

And one thing that isn't negotiable, whatever the reflux is doing. Sleep stays flat and on the back. Don't prop the cot, don't put anything under the mattress, don't use an inclined sleeper, they've been recalled after deaths, and don't put her on her front or her side. No safe-sleep authority makes an exception for reflux, and this is the point on which I'd be least willing to be talked round, by anybody, including my own mother.

Reflux stops being a laundry question and becomes a medical one at a fairly clear line.

• Weight gain that has flattened, or weight crossing downward through centiles.
• Refusing feeds, or real distress and arching during most of them.
• Forceful or projectile vomiting after most feeds, particularly under two months.
• Green or bile-stained vomit, or blood in vomit or stools, which is emergency care now.
• A persistent cough or wheeze, or repeated chest infections.
• Regurgitation beginning for the first time after six months, or continuing past twelve to eighteen.
• Any of it alongside eczema, blood or mucus in the nappy or diarrhoea, which raises cow's milk protein allergy.

Take that to a doctor before you start anything yourself, because several quite different conditions look identical from the outside, and reflux medications aren't harmless and are prescribed to infants a good deal more often than the guidelines support.

I'll end where I began. I burped five babies rigorously and called a great deal of ordinary reflux wind, because wind was the word I'd been given, and having the right word earlier would have saved me some worry and my children a great deal of patting.

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What people ask me

What I read before I wrote

• Rosen et al. (2018), JPGN 66:516-554: Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: NASPGHAN and ESPGHAN joint recommendations
• NHS: Reflux in babies
• American Academy of Pediatrics: Burping, hiccups and spitting up
• The Lullaby Trust: Safer sleep advice
• HealthHub: Ministry of Health Singapore

This guide is general information, written to help you understand a topic and ask better questions. It is not medical advice and does not replace your own doctor, midwife or paediatrician. Anything that worries you about your baby belongs with them.

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