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Gastroesophageal Reflux

What is Gastroesophageal Reflux

All babies spit up from time to time. Normal spitting up results from having fed a little too much or a little too fast, or from being put in a position where there’s pressure on the full tummy. As babies feed, they naturally swallow some air along with the milk or formula. This happens much more with bottle-fed than breast-fed babies. When the air reaches the stomach, it starts to expand as it warms up to baby body temperature. This can cause some discomfort, and it is the reason babies need to burp after feeding. If some of the liquid they just swallowed is in front of the gas bubble, it will come out ahead of the burp, as spit up milk. Please remember that spitting up and vomiting are not really the same thing. Vomiting is a forceful squeezing of the stomach muscle that pushes most of the contents backwards and out the mouth. There’s usually a pretty large volume of liquid, and it may be mixed with mucous. Vomiting babies often seem ill, and/or have other symptoms such as pain or diarrhea. Spitting up is just a bit of liquid “washing up” backwards. The stomach isn’t really pushing the material out, and the baby usually looks fine.

Some babies spit up much more than normal and doctors say that these babies have “reflux,” or “gastroesophageal reflux.” There are actually two different kinds of reflux. Babies with “acid reflux” have abnormally high acid levels that come up their esophagus (food tube). This is painful for the baby (it’s what adults call “heart burn”) and can lead to problems feeding or to breathing problems such as asthma. Doctors sometimes refer to acid reflux as “GERD” (for “Gastro-Esophageal Reflux Disease). “Non-acid reflux” is what most “spitty babies” have. In non-acid reflux, it’s really just milk or formula coming up the esophagus. It doesn’t cause nearly as much distress for the baby and it doesn’t usually interfere with feeding or cause other major problems. We’ll just use the term “reflux” in this Aftercare Instruction.

Doctors diagnose reflux in many different ways. In most cases they can get enough information just from talking with the parents. Sometimes, doctors will do tests such as a probe that tests for acid coming up the esophagus (food tube) from the stomach. Sometimes they will do an X-ray test called a “barium swallow” or “swallowing study” to see what happens as the baby drinks and swallows milk. Doctors usually do these tests only in babies who are having serious problems with the reflux.

Babies with severe reflux tend to be younger and are often babies who were premature. Severe reflux can cause a number of problems, ranging from fussiness to poor weight gain to breathing problems like asthma. Fortunately, the vast majority of babies with reflux are just “spitty babies” who do well with a few minor changes in the way the are fed.

 Gastroesophageal Reflux Symptoms

Parents usually have two major concerns: the messiness and inconvenience of the spitting up, and the worry that the baby might have something more serious going on. Parents also naturally worry that the baby isn’t getting enough to eat if s/he’s spitting up so much. Fortunately, it turns out that all of us over-estimate the amount of liquid in vomit (it just looks so much worse than milk). That means that in most cases, even very spitty babies are getting plenty to eat and drink. A good bottom line to remember is that if the baby is gaining weight and growing normally, s/he is getting enough nourishment.

Doctors sometimes worry that very spitty babies could develop inflammation of their esophagus, or “esophagitis.” Another concern for doctors is the possibility of choking or inhaling some of the stomach contents into the lungs. This can cause “aspiration pneumonia.” These conditions are rare in healthy, full-term babies, but they can be quite troublesome for premature babies or babies who have chronic conditions such as cerebral palsy.

In rare cases, spitting up or reflux can be signs of something more serious, such as an obstruction or blockage in the stomach or intestines. Babies with developmental delay for a number of reasons may have trouble swallowing normally, and may spit up much more than normal. True vomiting, which is much more forceful and has a much larger volume, is always a sign of something not right, though often it’s just a stomach bug.

Gastroesophageal Reflux treatment

The first and simplest thing to do if your baby is spitting up a lot is to make sure that s/he isn’t over-feeding or swallowing too much air. Many vigorous and healthy babies love to eat, and they nurse very hard and fast. Since most parents love to feed their babies, this is normally a good thing. Sometimes, though, the baby gets carried away, and either drinks too much for his or her stomach to hold, or swallows so much air that s/he can’t get it out without spitting. To avoid these problems:

  1. Try to limit the amount your baby takes in any one feeding. Your doctor will tell you about how much formula the baby should take at each feeding, depending on age and size. If the baby still seems hungry, wait a few minutes before offering more. Babies often cry for many reasons, not just because they are hungry. Often, if you wait a few minutes, the baby will settle down and be content.
  2. Please try burping the baby more often during the feeding. Eager, “greedy” feeders swallow lots of air, especially if they are bottle-fed. If you burp the baby after every 2 ounces or so, s/he will accumulate less air at once in the stomach.
  3. Try to keep the baby upright for half an hour after feeding, in a swing seat or bassinette. Of course, you know not to put the baby down on his or her stomach to sleep (“Back to Sleep”), but even lying on the back can make reflux worse.
  4. Use a pacifier or binky after a feeding if the baby seems to be eager for more. This allows the baby to comfort him or herself by sucking without the risk of overfeeding. Doctors refer to this as “non-nutritive sucking,” and they know that it is actually important for a baby’s emotional and future speech development.
  5. Elevate the head of the baby’s bed or crib to promote emptying of the stomach. Please do this only according to the manufacturer’s instructions, and make certain that the bed or crib cannot slip or tip over.
  6. If you are bottle feeding, you might try switching to a collapsible or vented bottle, which will help to prevent the baby from swallowing air. If you need to continue to use rigid bottles, please avoid letting the baby suck the foam out at the end of the bottle feeding – this is just a tiny amount of formula mixed with a lot of air.
  7. If your baby seems constipated (hard, painful stools) and strains to have a bowel movement, please treat the constipation (you can read our Aftercare Instruction on Constipation). This will help to reduce the common reflux that happens during a bowel movement.

Most babies improve with those techniques. If your baby continues to be spitty, ask your doctor about thickening the feedings. Putting some thickener like rice cereal in the formula may help reduce the non-acid kind of reflux, though it probably doesn’t help much with acid reflux. Experts don’t all agree yet on how helpful thickening feedings can be, so please check with your doctor before doing it. If you do decide to try thickened feedings, start with a fairly small amount of thickener, and work your way up to the minimum amount it takes to make a difference.

In very severe cases of acid reflux, doctors may recommend using an anti-acid medication, or a “pro-kinetic” medication that helps move things forward out of the stomach. These are prescription-only drugs for infants, and most doctors recommend them only in very severe cases or if other problems such breathing problems occur. The most commonly used anti-acid medications are famotidine (Pepcid® and others) and ranitidine (Zantac® and others). The most common pro-kinetic medication is metaclopromide (Reglan®). This medicine does have some possible side effects, such as temporary stiffening of the muscles, that go away when you discontinue the drug. Some babies with particularly severe acid reflux, who are having lung problems or trouble gaining weight, may need to have an operation to narrow the lower end of their esophagus.

Dangerous  Symptoms

Spitting up is almost always a very benign problem, and usually more messy than it is dangerous. Most babies spit up a great deal between birth and about 6 months, and as long as your baby is gaining weight, growing well, and developing normally there’s usually nothing to worry about. Sometimes, though, spitting up may actually be vomiting, or it may be a sign of reflux that’s bad enough to need your doctor’s attention. Here are a few things to look out for:

  • Forceful vomiting – vomit that shoots out several inches or more from the baby’s mouth is sometimes called “projectile” vomiting
  • Worsening spitting up over a several week period, or new spitting up in a baby who had outgrown it
  • Evidence of abdominal pain, such as pulling up knees or crying while spitting up
  • Writhing or making faces just before spitting up
  • A baby who seems excessively irritable or sleepy during and after the episode of spitting up or vomiting
  • A baby who has stopped gaining weight, or who loses weight
  • Yellow or green-colored material, or blood, in the spit-up or vomit
  • Diarrhea

Signs of dehydration:

  • Sunken appearance of the eyes
  • Dry tongue and mouth (dry lips are common and are not a sign of dehydration)
  • A sunken fontanel (soft spot) in an infant
  • Less than normal urination, or dark or strong-smelling urine
  • Being too sleepy (lethargic) or being very irritable or fussy
  • Cold, pale hands and feet even if the room is warm

If any of these occur, please be sure to call your doctor’s office right away. If your child has any of the items listed above in bold print, please go directly to the emergency room.

Other points of concern

Infants rarely spit up because of their formula, though parents often find themselves changing formulas to try to help. Please have a thorough discussion with your doctor about whether s/he thinks changing formula will do your baby any good. Frequent formula changes are confusing to babies and can be expensive for parents.

As babies get older, parents often are excited to have the baby start trying more advanced foods and even table foods. While it is exciting to watch your baby growing up, please remember that for the first year of life, breast milk or formula should be the main source of nutrition. Experts recommend that most babies get nothing but breast milk or formula for the first few months. This can help cut down on food allergies and intolerances later in life. It may also help to cut down on vomiting. If your young baby is getting baby food or table food, and is having a problem with spitting up or vomiting, please try backing off a bit on the food items.

Other Conditions that Might Be Present with Gastroesophageal Reflux

Most spitty babies have nothing else really serious going on, and they outgrow the problem. There are a few things that can cause actual vomiting in young babies, though. Young infants and some older children can have a rare condition in which their intestines get twisted. These infants look very sick and are often vomiting, usually with greenish material. This is an emergency – please go directly to an emergency room if this happens. Babies around four to eight weeks of age can develop a partial blockage of the outlet of the stomach. These babies often start with mild vomiting that gets dramatically worse over 3-4 days. At its worst, the baby has true “projectile vomiting.” Older babies and toddlers can also get a temporary blockage of their intestines that causes bouts of pain mixed with periods of seeming normal. These babies may vomit or have blood in their stool. If you suspect any of these conditions, please call your doctor right away. Again: If your baby’s vomit is green, yellow, or blood-tinged, or if there’s blood in the stool, please go straight to an emergency room.

Plain old “stomach bugs,” which are really usually viruses, can cause diarrhea and vomiting. Sometimes the vomiting starts before the diarrhea, which can make parents worry. Some doctors recommend watching for up to 12 hours to see if diarrhea starts. If your doctor recommends that, please read our Aftercare Instructions for Diarrhea and Vomiting. If your baby has true vomiting without diarrhea for more than 12 hours, please call your doctor.