Dr. Susan Kressly is a board-certified pediatrician and a fellow of the American Academy of Pediatrics. She has a private practice in pediatrics and adolescent medicine and is Chairman – Department of Pediatrics at Doylestown Hospital in Pennsylvania.
So your child spits up after eating and you’ve heard this could be reflux (also known as GER or gastro-esophageal reflux). How is a parent to know? Let’s start with a little physiology lesson. When normal adults eat a meal, digestion begins with saliva in the mouth. When you swallow, the muscles in your esophagus move in a very coordinated way to push food into your stomach. Between the esophagus and the stomach there is a special ring-like band of muscle called the lower esophageal sphincter or gastro-esophageal sphincter. This closes after the food enters the stomach and then the stomach goes to work further digesting the food. This digested food then travels out of the stomach through the pylorus or pyloric sphincter to start its travel down the intestinal tract.
In normal infants, the gastro-esophageal sphincter is immature, which allows some backflow of stomach contents up the esophagus. Sometimes it comes all the way and the baby “spits up.” Sometimes you hear gurgling in the back of their throat and they hiccup or cough. Sometimes the backflow has such force that it comes through their nose. Usually the sphincter matures by six months of age, but some children take until 9-12 months. Often it gets worse at 4 months of age as infants start to move themselves. (Shake up a soda bottle and you are sure to have it fizz out the top!)
Since some degree of reflux is normal physiology of infants, how do you know when this normal process becomes reflux disease? Physicians worry about infants who are either not gaining weight, are miserable most of the day, and/or cough and wheeze.
Some infants spit up so much that they can’t keep enough calories down in order to gain weight. Some infants have “learned” not to put much in their stomach or it comes back up; they “self-limit” the amount they are willing to eat at any given feeding. The best way to find out if this is a problem is to have your pediatrician weigh your child and plot them on a growth curve, to see if she is gaining weight appropriately.
Much of the irritability of infants with reflux is dependent on the natural pH of their stomach contents. Most of us don’t mind if we burp up ice cream, but if it feels like jalapeno peppers, look out! Some infants with reflux will arch and fuss during and after a feeding. Some will give a throat-clearing cough when you lay them down to change their diaper (as their stomach contents splash up and hit them in the back of the throat.) Some will have watery eyes and turn red in the face when they spit up. (Remember having soda come up through your nose when you laugh? It stings!)
Some infants with wheezing actually have “silent reflux.” You may not notice the food coming up, but it reaches the level of the vocal cords, causing them to aspirate or inhale minute particles of food. This can be a presumptive diagnosis (your doctor decides based on the history and exam that this is the likely cause) or through a nuclear x-ray study called a “milk scan.” (Infants drink milk/formula tagged with a nuclear isotope and then are watched over time to see if any of it splashes up and into their lungs. Don’t worry, no pain involved!)
So what about treatment? Most treatment is focused on altering the pH of the refluxing contents with acid suppressors (Zantac, Pepcid, Prevacid, etc.). It is important to note that these medicines will NOT keep your infant from spitting up. They will just make it less bothersome because the pH will be neutralized.
Positioning can help. It is harder to throw up uphill! Hold your baby upright after feeding. Elevate the head of the crib/bassinette by putting towels/blankets under the mattress to make a 30-degree inclined plane. (Remember how they tilted the bassinettes in the nursery?) Some infants are more comfortable in a cloth infant “bouncy” seat, which props the infant upright but allows them to remain stretched out. Sometimes hard car seats/infant seats cause infants to slump down and bend at the waist, which puts more pressure on the pylorus and can make the problem worse. Some infants with reflux hate riding in their car seats for this very reason.
Your doctor may recommend “thickening” your baby’s milk by putting cereal in the bottle. The usual recommended amount is 1 teaspoon to 1 tablespoon per ounce of formula/breast milk. Do NOT do this without first discussing it with your pediatrician.
Many infants who have reflux also have “delayed gastric emptying”; that is, they take a longer than average time to empty their stomachs. These are infants who haven’t eaten for 2 hours and then seem to throw up everything they ate. There are some medicines that help the stomach empty more rapidly (Reglan, for example). However, most physicians want to make sure an infant has normal anatomy before starting this medicine, so they will order an “Upper GI.” This procedure is an x-ray study where the infant drinks milk that has barium in it, and pictures are taken as the milk goes through the esophagus, into the stomach and out the pylorus into the intestines. These medicines are not first-line drugs because they have potential side effects. Your doctor will decide with you whether the risks are worth the potential benefits.
A word of caution: Sometimes reflux is confused with something called “pyloric stenosis.” This is a condition where the pyloric sphincter is too tight and the stomach contents cannot drain properly. Food backs up in the system and infants will vomit as a result. Usually these infants get progressively worse; they don’t have some good feedings and some bad feedings. Each day gets worse and often gets to the point where there is “projectile” vomiting (vomiting with such force that it shoots across the table). Pyloric stenosis is more common in first-born males, for reasons that are not understood. It can be diagnosed with an upper GI or an ultrasound of the pylorus. The treatment for this is surgical, to make the pylorus looser.
For both “spitty babies” and those with reflux, time is your best friend. Almost all infants outgrow this by the first birthday at the latest. In the meantime, don’t shampoo your carpets!
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