Is this spit-up normal?

By: Joseph Mechak, MD

The first thing we need to do is make an important distinction between Gastroesophageal Reflux and Gastroesophageal Reflux Disease.  These may sound the same but they are two very different things.
Gastroesophageal Reflux also known as Physiologic Reflux or “spit-up” is NORMAL.  100% of babies experience some degree of reflux during the first few months of life. This term simply refers to milk passing out of the stomach and back up into the esophagus.  Sometimes, it will go so far as to come out of the mouth or nose. It can be a little dribble or forceful.  It can be a few drops or look like a whole feed (hint: it never is).  Babies may cough or gag or give a sour look for a few seconds, but generally it does not bother them too much.  For this reason, we often call these babies ‘happy spitters.’  
In all of us, there is a muscle that sits atop the stomach called the lower esophageal sphincter (LES).  That muscle’s job is to prevent reflux from happening.  But in babies, this muscle is still very weak and isn’t very effective at its job yet. Physiologic reflux is usually worst in the first few months of life. As the LES strengthens over time, reflux usually goes away by 6 months of life or so.  

Let’s now contrast physiologic reflux with Gastroesophageal Reflux Disease (GERD). GERD is NOT normal and only a small number of babies have bon-a-fide GERD. GERD is physiologic reflux but painful, bothersome, or interferes with feeds. Physiologically, there is not much difference other than reflux in GERD contains a large amount of stomach acid.  The stomach is equipped to handle acid but the esophagus is not.  This acidic reflux burns esophagus causing what many of us know as heartburn.  GERD can impact your babies ability to feed, it can make them very uncomfortable, fussy during and after feeds, and can affect their weight gain and growth.  

This distinction between spit-up and GERD is important.  Spit-up can be frustrating but the most troublesome outcome is usually a few extra loads of laundry.  In GERD, however, we often need to intervene so that babies feel better and can eat and grow the way they need to.  There are few specific symptoms that are typical of GERD that can help make this distinction.  In GERD babies often have: 

  • Consistent and persistent fussiness shortly following feeds, especially when laid down
  • Pain, fussiness, back arching with spit-up
  • Pain or back arching with feeds
  • Feeding refusal
  • Poor weight gain or weight loss
  • Fewer than normal dirty or wet diapers

If you notice any of the signs above in your baby, you should talk to your doctor.  

There are a few tricks that can help reduce reflux, which in turn helps GERD as well.
Easy fixes:

  • Burp often.  More air in the stomach can lead to more reflux and more symptoms
  • Hold babies upright for 20-30 minutes after feeds.  This lets gravity move some of the milk through the stomach and into the intestine.
  • Try smaller feeds, more often. Talk to your pediatrician on how to best do this without disrupting your babies feeding cycles. 

Next steps:

  • Sometimes thickening feeds with cereal can help hold milk in the stomach.  There is not a lot of strong medical evidence to support this practice so talk to your pediatrician about the pros and cons first.
  • Food allergies are a whole other ball of wax but there can be some overlap between food intolerances and reflux.  Dairy, eggs, and soy in mom’s diet can create some digestive issues in babies.  Sometimes cutting these foods out of mom’s diet can help but you’d definitely want to talk with your pediatrician before going down this road.

Final steps:

  • Medicines – There are some medication options that can help with GERD.  Importantly, these medications are acid reducers and do NOT change the amount of reflux that occurs.  These medications are the same that you might take for heartburn.  These medications are safe but the goal is to be on them for as short a time as possible. The two most common meds used in our office:
    • Famotidine (Pepcid) – This is a type of H2-blocker that moderately blocks some acid producing cells
    • Lansoprazole (Prevacid) – This is a medication called a proton pump inhibitor which very powerfully reduces acid production in the stomach

The first few weeks and months of a baby’s life can be overwhelming and stressful.  If you are worried about your baby’s spit-up, don’t go it alone.  Contact the office to talk with one of our triage nurses or make an appointment with your doctor.  They can help walk you through all of the information above and help do what is best for your baby.