Every baby spits up…there is definitely a spectrum from the baby that spits up once in their whole life all the way to the baby that spits up every single time they eat.
So, if every baby spits up, how do I decide what is normal?
The answer to this is tricky but I’m hopeful that I can help you decide by reading further…
Studies have been done where they watch how many times a baby regurgitates milk and stomach acid by place a pH probe down the esophagus. The answer…30 times per day. Most but not all of these episodes were associated with milk at least making it into the mouth.
Why does this happen?
There is a muscle that sits on top of the stomach that is meant to properly relax and squeeze to allow milk into but not out of the stomach. Unfortunately, in most young infants, this muscle is both weak and dumb. It is not strong enough to override the pressure of the stomach pressing on it and it frequently relaxes when it is supposed to be contracting, letting stomach acid run back up into the esophagus.
So, reflux is, for the most part, a mechanical problem that is based on the pressure of the stomach and the strength of the muscle that sits on top of it. That is why I think that the most common cause of spitting up is overfeeding.
Often a family of a 2 month old will come in for their checkup and have questions about why their baby (who eats 6 ounces per feed) is spitting up. The issue is that the stomach is only a few ounces big at this age and everything else that you try to squeeze into it just raises the pressure and causes the baby to spit up.
So, if it’s so common what makes it abnormal?
There’s really only 2 reasons why I will treat babies for reflux: poor weight gain or associated pain/fussiness. So, the most common thing I will do to treat reflux is check the baby’s weight and if weight gain is good, reassure the family that they have a “happy spitter.”
I also see babies who are consistently fussy with their spitting or that have fussiness predictably during feeds or in the 30 minutes following each feed with or without spitting up. Some people have termed this “silent reflux” but I don’t really like that term because the screaming associated with it is anything but “silent.” Babies can also seen to be arching their backs which is sometimes confused for seizures but is, in fact, reflux.
What do we do about it?
Many babies can be helped by just cutting back on the amount of milk they are ingesting…most babies need about 2-3 ounces per feed at 2 months and this goes up about 1 ounce per month of age after (6 ounces at 6 months).
I still commonly have families slightly elevate the head of the crib although it looks like review of the literature questions whether this is actually helpful or not so I may have to rethink this.
Studies have shown varying percentages about babies with reflux who have an allergy or sensitivity to cow’s milk protein (some studies show it as high as 40%). Thus it is reasonable to try a short trial of a hypo-allergenic formula (Neutramigen or Alimentum). Many babies who are sensitive to cow’s milk will also be sensitive to soy so many publications do not recommend a trial of soy but because of the expense of the hypo-allergenic formulas I will sometimes have families do a trial of soy formula first.
There have also been some reports that breastfeeding moms ingesting sea salt can be helpful for their babies reflux. I can’t find any large studies assessing this but can’t see how it could be harmful. I can’t find a good source that gives a dose for a formula feeding baby.
Finally, in those babies who are not gaining weight well or who are fussy with their reflux or following feeds, a short trial of an antacid medicine can be attempted to help with symptoms. There are two types of medicines that can be used: H2-blockers (ex Zantac) and PPI (ex Prevacid). I try to remind families that neither of these medicines are meant to help keep milk in the stomach, they only change the acidity of the contents that are coming up. So, it is likely that the baby will continue to spit.
- Most babies with reflux have a laundry problem and not a medical problem (think happy spitter).
- Limiting overfeeding is the major non-medical treatment for spit up.
- Medicines for reflux can be used in babies with poor weight gain or fussiness but should be used sparingly and with appropriate expectations.