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Reflux (Spitting Up)

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Definition

  • Spitting up small amounts of breastmilk or formula. Also called reflux.
  • Spitting up 1 or 2 mouthfuls of milk at a time
  • No effort or crying
  • Normal symptom in half of young babies

Symptoms of Normal Spitting Up

  • Smaller amounts often occur with burping ("wet burps")
  • Larger amounts can occur after overfeeding
  • Most often seen during or shortly after feedings
  • Occurs mainly in children under 1 year of age
  • Begins in the first weeks of life
  • Caution: normal reflux does not cause any crying

Complications of Spitting Up (GERD)

  • Most infants are "happy spitters." Normal spitting up (normal reflux) occurs in half of babies. It does not cause crying or colic.
  • Normal crying occurs in all babies. Frequent crying (called colic) occurs in 15% of babies. Crying and colic are not helped by heartburn meds. These meds also have side effects.
  • If they develop complications, it's called GERD (gastro-esophageal reflux disease). This occurs in less than 1% of babies.

Symptoms of GERD

GERD problems occur in less than 1% of infants:

  • Choking on spit up milk
  • Heartburn from acid on lower esophagus. Infants with this problem cry numerous times per day. They also act very unhappy when they are not crying. They are in almost constant discomfort.
  • Poor Weight Gain

Cause

  • Poor closure of the valve at the upper end of the stomach (weak valve)
  • Main trigger: overfeeding of formula or breastmilk
  • More than half of all infants have occasional spitting up ("happy spitters")

Reflux Versus Vomiting: How to Tell

  • During the first month of life, newborns with true vomiting need to be seen quickly. The causes of vomiting in this age group can be serious. Therefore, it's important to tell the difference between reflux and true vomiting.

Reflux. The following suggests reflux (normal spitting up):

  • You've been told by a doctor your baby has reflux
  • Onset early in life (85% by 7 days of life)
  • Present for several days or weeks
  • No pain or crying during reflux
  • No effort with spitting up
  • No diarrhea
  • Your baby acts hungry, looks well and acts happy.

Vomiting. The following suggests vomiting:

  • Uncomfortable during vomiting
  • New symptom starting today or yesterday
  • Forceful vomiting
  • Contains bile (green color)
  • Diarrhea is also present or
  • Your baby looks or acts sick.

Pyloric Stenosis (Serious Cause)

  • This is the most common cause of true vomiting in young babies.
  • Onset of vomiting age 2 weeks to 2 months
  • Vomiting is forceful. It shoots out of the baby's mouth. This is called projectile vomiting.
  • Right after vomiting, the baby is hungry and wants to feed. ("hungry vomiter")
  • Cause: the pylorus is the channel between the stomach and the gut. In these babies, it becomes narrow and tight.
  • Risk: weight loss or dehydration
  • Treatment: cured by surgery.
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When To Call

Go to ER Now

  • Bile (green color) in the spit-up

Call Doctor or Seek Care Now

  • Blood in the spit up
  • Choked on milk and turned blue or went limp
  • Age less than 12 weeks and spitting up changes to vomiting (forceful or projectile)
  • Age less than 1 month old and looks or acts abnormal in any way
  • Your child looks or acts very sick
  • You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

  • You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

  • Chokes a lot on milk
  • Poor weight gain
  • Frequent crying
  • Spitting up is getting worse
  • Age more than 12 months old
  • Spitting up does not get better with this advice
  • You have other questions or concerns

Self Care at Home

  • Normal reflux (spitting up) with no problems
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Care Advice

What You Should Know About Spitting Up:

  • Spitting up occurs in most infants (50%).
  • Almost always doesn't cause any pain or crying.
  • Spitting up does not interfere with normal weight gain.
  • Infants with normal reflux do not need any tests or medicines.
  • Reflux improves with age.
  • Here is some care advice that should help.

Feed Smaller Amounts:

  • Skip this advice if age less than 1 month or not gaining weight well.
  • Bottlefed Babies. Give smaller amounts per feeding (1 ounce or 30 mL less than you have been). Keep the total feeding time to less than 20 minutes. Reason: overfeeding or completely filling the stomach always makes spitting up worse.
  • Breastfed Babies. If you have a good milk supply, try nursing on 1 side per feeding. Pump the other side. Switch sides you start on at each feeding.

Longer Time Between Feedings:

  • Formula. Wait at least 2½ hours between feedings.
  • Breastmilk. Wait at least 2 hours between feedings.
  • Reason: it takes that long for the stomach to empty itself. Don't add more milk to a full stomach.

Loose Diapers:

  • Do not put the diaper on too tight. It puts added pressure on the stomach.
  • Don't put pressure on the stomach right after meals.
  • Also, do not play too hard with your baby during this time.

Upright Position:

  • After meals, try to hold your baby in the upright (vertical) position.
  • Use a front-pack, backpack, or swing for 30 to 60 minutes after feedings.
  • Decrease the time in a sitting position (such as infant seats).
  • After 6 months of age, a jumpy seat is helpful. The newer ones are stable.
  • During breast or bottle feeds, hold your baby at a slant. Try to keep your baby's head higher than the stomach.

Less Pacifier Time:

  • Frequent sucking on a pacifier can pump the stomach up with swallowed air.
  • So can sucking on a bottle with too small a nipple hole.
  • The formula should drip 1 drop per second when held upside down. If it doesn't, the nipple hole may be clogged. Clean the nipple better. You can also make the nipple hole slightly bigger.

Burping:

  • Burping is less important than giving smaller feedings. You can burp your baby 2 or 3 times during each feeding.
  • Do it when he pauses and looks around. Don't interrupt his feeding rhythm in order to burp him.
  • Burp each time for less than a minute. Stop even if no burp occurs. Some babies don't need to burp.

Add Rice Cereal to Formula:

  • If your baby still spits up large amounts, try thickening the formula. Mix it with rice cereal.
  • Start with 1 level teaspoon of rice cereal to each ounce of formula.

Acid Blocking Medicines:

  • Prescription medicines that block acid production are not helpful for normal reflux.
  • These medicines also can have side effects.
  • They do not reduce excessive crying from colic.
  • They are only useful for symptoms of heartburn.

What to Expect:

  • Reflux gets better with age.
  • After learning to sit well, many babies are better by 7 months of age.

Call Your Doctor If:

  • Spitting up changes to vomiting (forceful or projectile)
  • Poor weight gain
  • Your baby does not get better with this advice
  • You think your child needs to be seen
  • Your child becomes worse

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Barton Schmitt MD, FAAP
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.
Copyright 2000-2024. Schmitt Pediatric Guidelines LLC.
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