By: Anthony Porto, MD, MPH, FAAP
All babies spit up— and it often seems like everything they just ate comes right back up!
So, how do you know if your spitty baby's symptoms are normal or part of a larger problem?
To help you sort it all out, the American Academy of Pediatrics (AAP) answers common questions about typical digestive functioning and explains the differences between gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD).
What are the differences between GER and GERD?
Without getting too technical, spit-up (also called reflux, gastroesophageal reflux, or GER) is the movement of stomach contents into the esophagus, and sometimes through the mouth and nose. When reflux is associated with other symptoms, or if it persists beyond infancy, it is considered a disease and is known as gastroesophageal reflux disease or GERD.
GER in infants is not considered a disease and does not include a "D." In fact, GER is considered normal. These infants are known as "happy spitters," because they are not cranky and do not appear to be in a great deal of pain when spitting up. In fact, your baby may feel better after a good spit-up. Other symptoms of GER include mild feeding problems, such as occasional prolonged feeds or interrupted feeds.
When is spit-up or GER normal?
GER usually begins at approximately 2 to 3 weeks of life and peaks between 4 to 5 months. Most babies who are born at full term will have complete resolution of symptoms by the time they are 9 to 12 months old.
In most babies, GER disappears as the upper digestive tract functionally matures. In addition, normal development, including improved head control and being able to sit up, as well as the introduction of solid food, will help improve GER symptoms.
What are the causes of GER?
If your baby's stomach is full or his or her position is changed abruptly, especially after a feeding, the stomach contents—food mixed with stomach acid—press against the valve at the top of the stomach. This is called the lower esophageal sphincter. This ring of muscle normally relaxes to let food pass from the esophagus into the stomach and then tightens again to keep the food there. When it is not fully developed or it opens at the wrong time, the stomach contents move back or reflux into the esophagus. See Why Babies Spit Up for more information on this.
In older children, diet can play more of a role. Large meals and highly acidic or spicy meals, as well as carbonated or caffeinated beverages, can lead to increased GER symptoms. In addition, GER is more common in children who are overweight or obese.
How do I know if my child has GERD?
Unlike GER, GERD is associated with complications from acid reflux. Call your pediatrician if your child exhibits any of the following signs or symptoms:
Refusal to feed
Crying and/or arching the back during feeds (i.e., seems to be in pain)
Blood or greenish color in the spit-up
Increase in frequency or intensity of the spit-up (i.e., forceful)
Belly is swollen or distended or feels hard
Respiratory symptoms—including wheezing and coughing
In addition, let your pediatrician know if you notice that your baby doesn't seem to be gaining weight or is having fewer wet and dirty diapers, as these may be signs that not enough of what he or she eats is staying down.
How will my pediatrician evaluate my baby for GER?
The AAP believes it is important for all pediatric health care providers to be able to properly identify and treat children with reflux symptoms, and to distinguish GER from more worrisome disorders to avoid unnecessary costs and treatments.
Your child's pediatrician will review your child's symptoms and feeding patterns and assess your child's growth by plotting his or her weight and height on a growth chart. This information will help them determine whether your child is a "happy spitter" or has symptoms of GERD.
How is GER or GERD treated?
While we wish we had a "quick fix" for babies who spit up, the truth is that for a good many spitty babies, it is mostly a matter of time. Lifestyle changes—including feeding and/or position changes—are recommended as first-line therapy for both GER and GERD. If GERD is severe, treatment may include medication or surgery. The surgery to correct reflux is called fundoplication.
Treatment options during infancy:
Burp at natural pauses in feeding and keeping your child upright for up to thirty minutes after feeding. If your bottle-fed baby spits up unusually often, your pediatrician may recommend thickening his or her formula with a very small amount of baby cereal. Never add solids to the bottle unless your pediatrician advises it. See Oatmeal: The Safer Alternative for Infants & Children Who Need Thicker Food for more information on this line of treatment.
Consider smaller and more frequent feedings, but be sure your baby is taking in enough to keep up typical growth and development.
Consider keeping your baby in an upright position for the first half hour or so after feeding. Always closely supervise your baby during this time.
Regardless of whether or not your baby warrants watchful waiting or medical intervention, the AAP does have additional and simple feeding suggestions that can help you deal with the situation at hand. See Remedies for Spitty Babies for more treatment tips.
Treatment options for an older child:
Avoid fried and fatty foods; they slow down the rate of the stomach emptying and promote reflux.
Peppermint, caffeine, and certain asthma medications can make the lower esophageal sphincter relax and allow stomach contents to reflux back into the esophagus. Some experts believe that tomato-based products have a similar effect. If any food seems to produce reflux or heartburn, keep it out of the diet for a week or two and then reintroduce it. If symptoms reoccur, avoid that food until your pediatrician recommends to reintroduce it into the diet.
Sometimes your pediatrician may recommend medications that neutralize or decrease the acid in your child's stomach to treat symptoms associated with GERD.
When might my pediatrician refer my child to a pediatric gastroenterologist?
Your pediatrician may refer your child to see a pediatric gastroenterologist, a pediatrician who has specialized training in problems of the gastrointestinal tract—including GERD—for a variety of reasons including:
A pediatric gastroenterologist will review your child's history, examine your child and review his or her diet history and growth charts. Sometimes, it can be helpful for a pediatric gastroenterologist to observe your child being fed or self-feeding. Based on the visit, he or she will decide whether your child may benefit from additional testing or from the addition of or a change in medications.
Additional Information & Resources:
About Dr. Porto:
Anthony Porto, MD, MPH, FAAP is a board certified pediatrician and board certified pediatric gastroenterologist. He is an Associate Professor of Pediatrics and Associate Clinical Chief of Pediatric Gastroenterology at Yale University and Director, Pediatric Gastroenterology at Greenwich Hospital in Greenwich, CT. He is also the medical director of the Yale Pediatric Celiac Program. Within the American Academy of Pediatrics, Dr. Porto sits on the PREP Gastroenterology Advisory Board and is a member of the Section on Gastroenterology, Hepatology and Nutrition. He is also a member of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition's Public Education Committee, a pediatric expert on nutrition for The Bump's Real Answers, and is the co-author of The Pediatrician's Guide to Feeding Babies and Toddlers. Follow him on Instagram @Pediatriciansguide.