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Should Your Child See a Doctor?

Spitting Up – Reflux

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Definition

  • The effortless spitting up (reflux) of 1 or 2 mouthfuls of stomach contents

Symptoms 

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

Cause 

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

Complications 

  • These complications occur in less than 1% of infants.
  • Choking on spit up milk
  • Heartburn from acid on lower esophagus
  • Poor weight gain

Reflux Versus Vomiting: How to Tell 

  • During the first month of life, newborns with true vomiting need to be seen immediately because the causes can be serious. Therefore, it's important to distinguish between reflux and true vomiting.
  • Reflux: The following suggest reflux (spitting up): infant previously diagnosed with reflux, onset early in life (85% by 7 days of life), present for several days or weeks, no discomfort during reflux, no diarrhea, hungry, looks well and acts happy.
  • Vomiting: The following suggest vomiting: uncomfortable during vomiting, new symptom starting today or yesterday, associated diarrhea, projectile or forceful vomiting, looks or acts sick.

When to Call Your Doctor for Spitting Up - Reflux

Call Your Doctor Now (night or day) If

  • Your child looks or acts very sick
  • Blood in the spit up
  • Choked on milk and turned bluish or became limp
  • Age under 1 month old and looks or acts abnormal in any way
 

Call Your Doctor During Weekday Office Hours If

  • You think your child needs to be seen
  • Chokes frequently on milk
  • Poor weight gain
  • Frequent unexplained fussiness
  • Spitting up becoming worse (eg. increased amount)
  • Age over 18 months
  • Spitting up doesn't improve with this approach
  • You have other questions or concerns
 

Parent Care at Home If

  • Normal reflux with no complications and you don't think your child needs to be seen
 

Home Care Advice for Spitting Up (Reflux)

  1. Reassurance:
    • Mild reflux occurs in most infants (50%).
    • Usually it doesn't cause any discomfort or complications.
    • Infants with normal reflux do not need any tests or medicines.
    • Reflux improves with age.
     
  2. Feed Smaller Amounts:
    • Skip this advice if age less than 1 month or not gaining weight well.
    •  Bottlefed: 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 filling the stomach to capacity always makes spitting up worse).
    • Breastfed: If you have a plentiful milk supply, try nursing on 1 side per feeding and pumping the other side. Alternate sides you start on.
     
  3. Longer Feeding Intervals:
    • Formula: Wait at least 2½ hours between feedings.
    • Breast milk: Wait at least 2 hours between feedings.
    • Reason: It takes that long for the stomach to empty itself. Don't add food to a full stomach.
     
  4. Loose Diapers: Avoid tight diapers. It puts added pressure on the stomach. Don't put pressure on the abdomen or play vigorously with your child right after meals.
  5. Vertical 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. Reduce time in sitting position (e.g., infant seats). After 6 months of age, a jumpy seat is helpful (the newer ones are stable).
  6. Less Pacifier Time:
    • Constant sucking on a pacifier can pump the stomach up with swallowed air.
    • So can sucking on a bottle with too small a nipple hole. If the formula doesn't drip out at a rate of 1 drop per second when held upside down, clean the nipple better or enlarge the hole.
     
  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 each time for less than a minute. Stop even if no burp occurs. Some babies don't need to burp.
     
  8. Expected Course: Reflux improves with age. Many babies are better by 7 months of age, after learning to sit well.
  9. Call Your Doctor If:
    • Your baby doesn't improve with this approach
    • Your child becomes worse
     

And remember, contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.


References

  1. Braganza S. Gastroesophageal reflux. Pediatr Rev. 2005; 26(8):298-299.
  2. Hillemeier AC. Gastroesophageal reflux: Diagnostic and therapeutic approaches. Pediatr Clin North Am. 1996;43:197-212.
  3. Khoshoo V, Edell D, Thompson A, et al. Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120(5):946-949.
  4. Mazur LJ with Baker RD, Boyle JT, Colletti RB, Gerson WT, Liptak GS, Rudolph CD, Werlin SL Gastroesophageal reflux. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 248-263
  5. Michail S. Gastroesophageal reflux. Pediatr Rev. 2007;28(3):101-110.
  6. Orenstein SR. Gastroesophageal reflux. Pediatr Rev. 1999;20:24-28.
  7. Spitzer AR, et al. Awake apnea associated with gastroesophageal reflux: A specific clinical syndrome. J Pediatr. 1984;104:200-205.

Disclaimer

This information is not intended to be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 8/1/2010

Last Revised: 9/22/2010 3:56:35 PM

Copyright 1994-2011 Barton D. Schmitt, M.D.

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