Definition

• Spitting up (normal reflux) is 1 or 2 mouthfuls of breast milk or formula
• No effort or crying with it
• Normal symptom in half of young babies

Health Information

Symptoms

• 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: Spitting up (normal reflux) does not cause any crying

How to Tell Spitting Up From Vomiting

• 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.
• Spitting up. The following suggests spitting up or normal 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:
• New symptom starting today or yesterday
• Uncomfortable during vomiting
• Forceful vomiting OR contains bile (green color)
• Diarrhea may also be present OR your baby looks or acts sick.

Cause

• Poor closure of the valve at the upper end of the stomach. Main trigger: overfeeding of milk.
• More than half of all infants have occasional spitting up ("happy spitters")
• Heartburn from acid on lower esophagus occurs in less than 1% of refluxers. Infants with this condition cry numerous times per day. They also act very unhappy when they are not crying. They are in almost constant discomfort. These are the refluxers who can be helped by acid blocking drugs.
• Most excessive crying is caused by colic, not reflux

Care Advice

1. Overview:
   • Spitting up (normal reflux) occurs in most infants (50%). Caused by a weak stomach valve.
   • Rarely causes any pain or crying.
   • Spitting up does not interfere with normal weight gain.
   • Infants with normal reflux do not need any tests or medicines. It improves with age.
   • Here is some care advice that should help.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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 for less than a minute. Stop even if no burp occurs. Some babies don’t need to burp.
8. Add Baby Cereal to Formula:
   • If your baby still spits up large amounts, try thickening the formula. Mix it with a baby cereal.
   • Start with 1 level teaspoon of cereal to each ounce of formula.
   • Oatmeal baby cereal is best.
9. 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.
10. 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
• Poor weight gain
• Your baby does not get better with this advice
• You think your child needs to be seen
• Your child becomes worse

Author: Barton Schmitt MD, FAAP

Copyright 2000-2020 Schmitt Pediatric Guidelines LLC

Disclaimer: This health information is for educational purposes only. You the reader assume full responsibility for how you choose to use it. The information contained in this handout should not be used as a substitute for the medical care and advice of your pediatrician. Listing of any resources does not imply an endorsement.

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