Spitting up

by Dr. Gregory Gordon

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All babies spit up, but few need medical treatment. It is important to differentiate normal spitting up from GERD (gastroesophageal reflux disease).

Normal spit-up is non-projectile vomiting of white to yellowish, often curdled, milk in a happy child who continues to grow well. This spitup often looks like a large amount and may soak the baby and their parent. Projectile vomiting, on the other hand, sprays out with force and can be a sign of a more severe problem.

GERD is the extreme form of spitting up. Spitting up becomes a medical problem when it affects an individual’s growth or causes pain.

Parents often report their child “spits up everything he eats.” While it may look like this to the concerned parent, most babies only spit up a fraction of their milk. Try pouring a few ounces of milk on your floor or a burp cloth. You will quickly see that an amount of normal spit-up is not the full feeding. If the child continues to grow well, I am not concerned about the reported volume of spit up. In my pediatric practice I have yet to see a child who spit up so much they did not gain weight.

The more common treatable concern with GERD is fussiness. When acid from the stomach comes up into a child’s esophagus, it can cause inflammation and pain. It is important to note that not all patients with GERD visibly spit up. As long as the acid travels up the esophagus it can cause the pain and fussiness of GERD. Symptoms include general fussiness, spitting up, increased fussiness when lying  at and arching the back.

Why do so many babies spit up?

When adults or older children eat, a muscle at the top of the stomach called the lower esophageal sphincter tightens and prohibits the stomach contents from going into the esophagus. Babies universally have poorly-developed lower esophageal sphincters and therefore all have some degree of gastroesophageal reflux. Fortunately, as children age, this usually resolves naturally.

To evaluate for GERD, many physicians will order an upper GI. This is a radiology study done after a child drinks barium then serial x-rays are taken. The test lasts only 5 to 10 minutes. Some physicians wrongly consider this the diagnostic test for GERD. It is possible that a child with severe GERD may not show any episodes during the short study time. In my opinion, upper GIs are overused and not needed to diagnose most cases of GERD. The diagnosis is made on history, physical exam and response to treatment.

Treatment for GERD in infants

Universal GERD recommendations:

• Holding the infant upright for 30 minutes a er feeding.
• Burping frequently during feeds.
• Elevating the head of their bed, so that they sleep at a 30-degree angle.

Severe cases of GERD may require:

Adding rice cereal to the child’s milk. This obviously requires more effort if the child is breastfeeding. The idea is increased viscosity can keep the milk in the stomach. Medical research shows to make a significant difference you need to add at least one tablespoon of rice per ounce of milk. This amount of rice is impractical, as it is difficult if not impossible to pass this through a nipple. When I do recommend adding rice cereal, I start at one teaspoon per ounce of milk. Even with a third less rice cereal, parents often have to widen the nipple.

Zantac or other acid-preventing medication. When children with GERD are fussy, I often prescribe Zantac. Zantac and other similar medications decrease the amount of acid produced in the stomach. For patients with reflux, less acid should mean less pain and fussiness. These acid-preventing medications do not reduce the amount a child spits up, but they should reduce a GERD patient’s pain.

In pediatrics, the vast majority of cases of GERD will get better with time. As children grow, their diet becomes less liquid, they learn to walk upright and their stomach musculature (lower esophageal sphincter) matures. These factors lead to GERD symptoms naturally resolving between 6 to 18 months of age.

Dr. Gregory Gordon

Dr. Gregory Gordon grew up in Gainesville, Florida. He attended the University of Florida for both his undergraduate and medical degrees. After he completed his pediatric residency at the University of Alabama at Birmingham, he joined Pediatric Associates of Orlando. Dr. Gordon is the proud father of seven children. He is the Vice President of “The Gift of Swimming” (a local charity that provides swim lessons to Orlando’s needy children). In early 2010, encouraged by his patients, he started gregorygordonmd.com to share his pediatric and parenting experience.