The Word on GERD

Spitting up is one of the most common issues I discuss with parents of babies. In this article, I’ll try to give some useful advice on spit-up, reassure the parents of “happy spitters,” and point out some red flags that would warrant a call to your healthcare provider. I’m going to focus on children under a year old without special healthcare needs or anatomic abnormalities, who may have other, more serious causes of spitting up. As always, this article is intended as general medical information and not specific medical advice for your child. If you have questions or concerns, always call your friendly neighborhood pediatrician.

Why Is My Baby Spitting Up?
The medical term for spitting up in a baby is gastroesophageal reflux, or GER. GER is pretty much a normal state of affairs for many babies; about half of all babies spit up at least once a day. Milk or formula easily flows from the stomach up the esophagus and out of the mouth. (The esophagus is the tube that connects the mouth and stomach.) Babies do not have great muscle control, and they have a floppy junction between the stomach and esophagus. In most babies, milk or formula flows out effortlessly and painlessly. These babies are “happy spitters”:  they spit up – sometimes a lot! – but they grow normally, they have a normal number of wet diapers, and they are not excessively fussy. (The volume of spit-up may appear shocking, but try spilling just half an ounce of water on a flat surface, or on your shirt – a little goes a long way!) Spitting up usually peaks at four months and resolves by 12-18 months.

What Is GERD?
In some babies, spitting up causes problems. A baby may cry excessively, arch her back, or refuse the breast or the bottle. Sometimes the spitting up is so severe a baby will cough frequently, have breathing difficulties, choke, or fail to gain weight appropriately. In this situation, the spitting up is not just regular GER, it is gastroesophageal reflux disease (GERD).

What can you do if you have a “happy spitter” or even a baby with mild GERD? First, avoid overfeeding. If your baby spits up, do not immediately start feeding or try to “re-feed” the lost milk or formula. Look for cues that your baby is done eating (such as turning away). Take frequent breaks to gently burp your baby. Try to feed your baby in a semi-upright position, and hold him upright for 15-30 minutes after feeding. Elevate the head of the crib by placing blocks or books under the legs at one end. (Do not prop your baby on a pillow or rolled towel, which poses a risk for suffocation.) Ask your healthcare provider if your baby is growing appropriately and is taking an appropriate amount of milk or formula. Keep in mind that happy spitters do not truly have a medical problem – although you may have a laundry problem!

What about changing formula, or adding cereal to thicken the formula? If a baby has a milk allergy or intolerance, she may have fewer symptoms with a hypoallergenic formula. If a formula change is made, it may take two weeks to see a difference. Keep in mind that not all babies who spit up have a milk intolerance. (Further discussion of milk intolerance is beyond the scope of this article, but talk to your pediatrician if you have questions.) Adding one tablespoon of rice or oat cereal to each ounce of formula (or pumped breast milk) may decrease the number of spit-up episodes. However, you may have to experiment with different bottle nipples to get adequate flow with thicker formula. It’s not clear how adding cereal affects future risk of obesity, but it significantly increases the calories in formula. (For those interested in the math: formula and breast milk both have about 20 calories per ounce; adding 1 tablespoon of rice cereal to 1 ounce of formula boosts it to 34 calories.) Changing formula or thickening feeds are strategies that should be reserved for problematic spit-up in consultation with your pediatrician.

When Should I Call My Doctor?
When is spitting up worrisome? The following are some red flags that signal GERD (with a D) or something more serious may be going on. If any of these occur, call your doctor or seek prompt medical attention.

• Vomiting blood or bright green bile
• Repeated projectile vomiting
• Difficulty eating or food refusal
• Failure to gain weight, or weight loss
• Inconsolable crying or extreme irritability
• Breathing problems like chronic cough or wheezing
• Recurrent lung or ear infections
• Episodes of choking, turning blue, or stopping breathing

GERD is usually diagnosed by taking a history and doing a physical exam. Sometimes, a healthcare provider may prescribe acid-suppressing medications for GERD. Complicated cases may benefit from consultation with a gastroenterologist (a specialist in the digestive system). In most cases, though, it is a benign condition that your baby will outgrow on her own.

Source:
Gastroesophageal Reflux: Management Guidance for the Pediatrician. Jenifer R. Lightdale, David A. Gremse and SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION. Pediatrics 2013;131;e1684; originally published online April 29, 2013

Dr. Ben Kleifgen is a pediatrician with First Steps Pediatrics and Adolescent Medicine in western Pennsylvania and surrounding areas of West Virginia and Ohio. He graduated from Temple University School of Medicine and completed his pediatric residency at the University of Arizona in Tucson.