Excessive spitting up

Baby Spit Up - What Is Normal & When To Be Concerned?

NewbornPediatric Gastroenterology

Reviewed By Sharad Kunnath, M.D.

Spitting up is normal and completely harmless for most infants. When the spitting up or vomiting becomes too frequent, your child may have Gastroesophageal Reflux (GER). This reflux is a result of an immature digestive system and the poor closure of the valve (ring of muscle) at the upper end of the stomach. Most reflux or spitting up occurs during or after a meal, when the stomach, or tube that connects the stomach, is full. GER can begin during the first few weeks of life, peaking around 4 months and ending by 12 months of age. As long as your baby is not experiencing any discomfort and is making the appropriate weight gain, he/she is a healthy and normal infant.

Boys Town Pediatric Gastroenterology offers parents tips to help reduce GER:

Do not over feed your baby. More frequent, smaller feedings may reduce vomiting.
Add rice cereal to bottle feedings. (1 Tablespoon of rice cereal per 1 ounce of formula or breast milk)
Keep your baby in an upright position for 30 minutes after feeding.
Burp your baby during and after feedings.
Do not smoke around your baby.
Elevate your baby’s head during sleep. (According to the American Academy of Pediatrics, the best sleep position for a baby is on his/her back).
Avoid tight diapers or elastic waistbands that put pressure on baby’s abdomen.

Contact your physician right away if your child’s condition is severe, worsens or you notice the following symptoms:

Blood or a yellow or green fluid when vomiting
Poor weight gain or growth
Difficulty eating
Inconsolable or severe irritability
Difficulty breathing, wheezing, turning blue, chronic cough or breathing stops

Always contact your physician if you have questions or concerns about your baby’s health. If GER symptoms continue, you may choose to see a Pediatric Gastroenterologist—a medical doctor who specializes in the digestive health care of infants, children and adolescents.

Newborn Pediatric Gastroenterology

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Spitting Up - Reflux

Is this your child's symptom?

Spitting up small amounts of breastmilk or formula. Also called reflux.
Spitting up 1 or 2 mouthfuls of milk at a time
No effort or crying
Normal symptom in half of young babies

Symptoms of Normal Spitting Up

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

Complications of Spitting Up (GERD)

Most infants are "happy spitters." Normal spitting up (normal reflux) occurs in half of babies. It does not cause crying or colic.
Normal crying occurs in all babies. Frequent crying (called colic) occurs in 15% of babies. Crying and colic are not helped by heartburn meds. These meds also have side effects.
If they develop complications, it's called GERD (gastro-esophageal reflux disease). This occurs in less than 1% of babies.

Symptoms of GERD

GERD problems occur in less than 1% of infants:

Choking on spit up milk
Heartburn from acid on lower esophagus. Infants with this problem cry numerous times per day. They also act very unhappy when they are not crying. They are in almost constant discomfort.
Poor Weight Gain

Cause

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

Reflux Versus Vomiting: How to Tell

During the first month of life, newborns with true vomiting need to be seen quickly. The causes of vomiting in this age group can be serious. Therefore, it's important to tell the difference between reflux and true vomiting.

Reflux

The following suggests reflux (normal spitting up):

You've been told by a doctor your baby has reflux
Onset early in life (85% by 7 days of life)
Present for several days or weeks
No pain or crying during reflux
No effort with spitting up
No diarrhea
Your baby acts hungry, looks well and acts happy.

Vomiting

The following suggests vomiting:

Uncomfortable during vomiting
New symptom starting today or yesterday
Forceful vomiting
Contains bile (green color)
Diarrhea is also present or
Your baby looks or acts sick.

Pyloric Stenosis (Serious Cause)

This is the most common cause of true vomiting in young babies.
Onset of vomiting age 2 weeks to 2 months
Vomiting is forceful. It shoots out of the baby's mouth. This is called projectile vomiting.
Right after vomiting, the baby is hungry and wants to feed. ("hungry vomiter")
Cause: the pylorus is the channel between the stomach and the gut. In these babies, it becomes narrow and tight.
Risk: weight loss or dehydration
Treatment: cured by surgery.

When to Call for Spitting Up - Reflux

Call Doctor or Seek Care Now

Blood in the spit up
Choked on milk and turned blue or went limp
Age less than 12 weeks and spitting up changes to vomiting (forceful or projectile)
Age less than 1 month old and looks or acts abnormal in any way
Your child looks or acts very sick
You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

Chokes a lot on milk
Poor weight gain
Frequent crying
Spitting up is getting worse
Age more than 12 months old
Spitting up does not get better with this advice
You have other questions or concerns

Self Care at Home

Normal reflux (spitting up) with no problems

Seattle Children's Urgent Care Locations

If your child’s illness or injury is life-threatening, call 911.

Bellevue
Everett
Federal Way
Seattle

Care Advice for Spitting Up (Reflux)

What You Should Know About Spitting Up:
- Spitting up occurs in most infants (50%).
- Almost always doesn't cause any pain or crying.
- Spitting up does not interfere with normal weight gain.
- Infants with normal reflux do not need any tests or medicines.
- Reflux improves with age.
- Here is some care advice that should help.
Feed Smaller Amounts:
- Skip this advice if age less than 1 month or not gaining weight well.
- Bottlefed Babies. 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 completely filling the stomach always makes spitting up worse.
- Breastfed Babies. If you have a good milk supply, try nursing on 1 side per feeding. Pump the other side. Switch sides you start on at each feeding.
Longer Time Between Feedings:
- Formula. Wait at least 2½ hours between feedings.
- Breastmilk. Wait at least 2 hours between feedings.
- Reason: It takes that long for the stomach to empty itself. Don't add more milk to a full stomach.
Loose Diapers:
- Do not put the diaper on too tight. It puts added pressure on the stomach.
- Don't put pressure on the stomach right after meals.
- Also, do not play too hard with your baby during this time.
Upright 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 after feedings.
- Decrease the time in a sitting position (such as infant seats).
- After 6 months of age, a jumpy seat is helpful. The newer ones are stable.
- During breast or bottle feeds, hold your baby at a slant. Try to keep your baby's head higher than the stomach.
Less Pacifier Time:
- Frequent sucking on a pacifier can pump the stomach up with swallowed air.
- So can sucking on a bottle with too small a nipple hole.
- The formula should drip 1 drop per second when held upside down. If it doesn't, the nipple hole may be clogged. Clean the nipple better. You can also make the nipple hole slightly bigger.
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.
Add Rice Cereal to Formula:
- If your baby still spits up large amounts, try thickening the formula. Mix it with rice cereal.
- Start with 1 level teaspoon of rice cereal to each ounce of formula.
Acid Blocking Medicines:
- Prescription medicines that block acid production are not helpful for normal reflux.
- These medicines also can have side effects.
- They do not reduce excessive crying from colic.
- They are only useful for symptoms of heartburn.
What to Expect:
- Reflux gets better with age.
- After learning to sit well, many babies are better by 7 months of age.
Call Your Doctor If:
- Spitting up changes to vomiting (forceful or projectile)
- Poor weight gain
- Your baby does not get better with this advice
- You think your child needs to be seen
- Your child becomes worse

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

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 11/05/2022

Last Revised: 01/13/2022

Why does the baby spit up after feeding?

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Regurgitation is a common condition in newborns and infants and is most often a normal variant. However, it is not uncommon for parents to worry if their baby is spitting up frequently, believing that it is due to nutritional or health problems in general. Sometimes these fears are not unfounded, and regurgitation really has a pathological origin. What is its cause and when should you really consult a doctor about this?

Regurgitation - Return of a small amount of food (uncurdled or partially curdled milk) from the stomach up the digestive tract: into the esophagus and further into the oral cavity. According to statistics, at least 1 time during the day, at least 50% of babies from 0 to 3 months old can spit up, more than 60% of children 3-4 months old, and in 5% of children spit up continues up to the year ¹.

Regurgitation in newborns is considered a physiological process. It is caused by a number of factors, including:

Features of the structure of the upper digestive tract in babies
In newborns and infants up to a year of life, the stomach has a spherical shape. It holds a small amount of food, besides, the release from it into the duodenum is slower in comparison with children after the year ².
Weakness of the lower esophageal sphincter that separates the esophagus from the stomach
Normally, the lower esophageal sphincter should tightly "close" the esophagus, allowing food to pass into the stomach and not allowing it to enter back into the upper digestive tract. However, in young children (up to a year), the muscles of the esophageal sphincter are poorly developed, and it does not do its job very well ² .
Slow movement of food through the gastrointestinal tract
The neuromuscular system of newborns is immature. It does not ensure the proper movement of food through the esophagus, causing regurgitation.

One of the important risk factors contributing to regurgitation in newborns is aerophagia. This is the swallowing of large amounts of air during feedings. This happens when the baby is not properly attached to the breast, the mother has a lack of breast milk, or the bottle is in the wrong position in the child who receives the mixture. The size of the opening in the nipple also matters - if it is too large, the newborn swallows a lot of air ³ .

With aerophagia, the baby becomes capricious, restless immediately after feeding. Noticeable bloating. If the baby spits up immediately after a feed, the milk (or formula) remains practically fresh, uncurdled ³ .

Promotes regurgitation after feeding and a predominantly horizontal position of the baby during the day, combined with relatively high intra-abdominal pressure ⁴ . Therefore, the correct position of the baby after feeding is so important. To avoid regurgitation of an excessive amount of stomach contents, after feeding, it is necessary to hold the baby in an upright “column” position for some time (10-20 minutes), lightly patting on the back and allowing excess air to “exit”.

Regurgitation in many newborns can be provoked by other situations in which pressure in the abdominal cavity increases and stomach contents are thrown into the esophagus, in particular ³ :

tight swaddling;
stool disorders, in particular constipation;
long, forced cry and some others.

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Start with a baby bottle with an anti-colic system that helps you avoid common feeding problems such as colic, gas and spitting up*

How can you tell the difference between normal spitting up and vomiting?

Sometimes regurgitation is considered a manifestation of disorders in the digestive tract of children. Due to the constant reflux of acidic stomach contents into the upper sections, inflammation and other complications may develop, including growth retardation, a decrease in hemoglobin levels, and others. Therefore, it is important for parents to understand where the line is between physiological and pathological regurgitation ¹ .

If the mother is worried that her baby is spitting up, keep track of when this happens and count the total number of spit ups per day. Normally, regurgitation usually occurs after eating (the child burps after each feeding), lasts no more than 20 seconds and repeats no more than 20-30 times a day. With pathology, the problem manifests itself at any time of the day, regardless of when the baby was fed. Their number can reach 50 per day, and sometimes more ¹ .

The amount of discharge during regurgitation also matters. With normal, physiological regurgitation, it is approximately 5 - 30 ml. If this volume fluctuates between 50 and 100 ml, it is already defined as profuse vomiting. When the range of the jet of vomit is up to 50 cm, doctors talk about "vomiting a fountain." A variant of atonic vomiting is possible, when the contents of the stomach flow "sluggishly". It occurs with atony of the stomach (decrease in muscle tone of the stomach wall) and disruption of the esophagus ¹ .

Vomiting in babies is a warning sign. Doctors are especially alarmed by repeated vomiting, a fountain, with an admixture of bile, in combination with constipation. Vomiting can lead to the development of dehydration, acid-base imbalance and other consequences, so if it occurs, you should urgently contact your pediatrician to find out the cause and start treatment. A doctor's consultation is necessary if the child is spitting up a lot (more than 15-30 ml at a time), with a frequency of more than 50 episodes per day ^1.3 .

Physiological regurgitation: symptoms

Regurgitation in newborns, which is considered a normal variant and does not cause concern to pediatricians ³ :

usually continues for a certain period of time;
is characterized by slow, "passive" leakage; if the baby spits up a fountain, it is better to consult a doctor;
has a sour smell of curdled milk;
occurs without the participation of muscles - the baby does not strain during regurgitation;
does not affect the general well-being of the baby.

How to help a newborn who spit up often?

If the baby is healthy, no medication is prescribed for spitting up. To help the child allow simple measures based on lifestyle changes and feeding.

Frequent feeding of the baby
It is known that the baby is more prone to spit up if his stomach is full. To improve the situation, it is recommended to feed the baby more often, avoiding oversaturation, best of all - on demand ⁵ .

Correct feeding technique
Every feeding, the mother must ensure that the baby does not swallow too much air during suckling. When sucking, there should be no loud, smacking, clicking sounds. You also need to control that the baby captures the nipple along with the areola.

Choosing the right bottle and nipple
If the newborn is bottle-fed and receiving formula, it is important to choose the right bottle and nipple. The hole in it should be such that the milk flows out in drops, and not in a stream. The nipple must not be filled with air
New Anti-colic bottle with AirFree valve

The AirFree valve prevents air from entering the baby's stomach.
- Baby standing upright after eating
To allow air that has entered the digestive tract during meals to escape, it is important to keep the newborn upright for 10-20 minutes after feeding ⁴ .
- Ensure the correct position of the baby during sleep
To reduce the negative impact of the acidic contents of the stomach on the esophagus, it is necessary to put the baby to sleep in the supine position. The side or prone position, which many pediatricians used to recommend, is no longer recommended. It was found to be associated with an increased risk of sudden infant death syndrome ⁵ .

If parents notice alarming symptoms, such as spitting up too often or large volume, etc., it is important to consult a pediatrician without delay. This will allow you to identify the real problem in time and help the baby grow up healthy and happy.

References
¹ Zakharova I. N., Andryukhina E. N. Regurgitation and vomiting syndrome in young children // Pediatric pharmacology, 2010. V. 7. No. 4.

Nagornaya 2900 V., Limarenko M. P., Logvinenko N. G. Experience with the use of domperidone in suspension in young children with regurgitation syndrome // Child Health, 2013.
No. 5 (48).

³ Zakharova IN Regurgitation and vomiting in children: what to do? //Pediatrics. Supplement to Consilium Medicum, 2009. No. 3. S. 58-67.

⁴ Zakharova I. N., Sugyan N. G., Pykov M. I. Regurgitation syndrome in young children: diagnosis and correction // Effective pharmacotherapy, 2014. No. 3. P. 18-28.

⁵ Vandenplas Y. et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) //Journal of pediatric gastroenterology and nutrition. 2009; 49(4): 498-547.

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Regurgitation in infants
Regurgitation in children of the first year of life. Recommendations for young parents.

Parents have a lot of questions with the birth of a child. Moreover, it has been noted that almost all parents face the most exciting problems regarding the health of the baby, since all of them are mostly physiological, passing as the child grows and the work of all systems of his body becomes established. After all, a newborn child is not a small adult, absolutely all the organs and systems of the baby will not only grow in size, but also mature. However, even an understanding of this fact does not reduce the anxiety of parents when any deviations appear in the child's condition, even if they pass over time.
One of these exciting problems is regurgitation in children of the first year of life. According to statistics, a fairly large percentage of all infants, namely from 25% to 80%, have manifestations of the so-called regurgitation syndrome. Moreover, in half of the children, it is stubborn. What is the reason for such a high frequency of this syndrome? And what is it all about - regurgitation?
Regurgitation is the reflux of stomach contents into the mouth shortly after ingestion in infants, predominantly in the first six months of life. There are a number of reasons for the occurrence of regurgitation, both physiological and related to the care and feeding of the baby.

From the point of view of the characteristics of the child's body:
- The stomach is not elongated, as in an adult, but spherical in shape.
- Insignificant volume of the stomach.
- The sphincter (circular muscle), which opens the entrance to the stomach when food passes through the esophagus and closes it at the time of digestion, is rather weak, while the "pylorus", the same muscle, but at the junction of the stomach into the duodenum, is stronger. This feature contributes to the occurrence of regurgitation. A cavity closed on one side arises and with an increase in pressure in the cavity of the stomach, a weak sphincter opens and a reverse reflux of food into the esophagus is formed, and from there the oral or nasal cavity.
- It follows that overfeeding a child or swallowing air during feeding, contribute to an increase in pressure in the stomach, and therefore will inevitably lead to regurgitation.
- The presence of constipation in a child, increased flatulence, bloating can also cause unpleasant symptoms.
How to distinguish regurgitation from other, serious symptoms, indicating not just the immaturity of the baby's systems, but the occurrence of certain diseases that require examination by a pediatrician.

Regurgitation:
- Starts suddenly, without any previous symptoms.
- Occur without tension of the muscles of the anterior abdominal wall.
- Not accompanied by pallor, sweating, impaired well-being of the child.
- The child is still active, with a good appetite, and sufficient weight gain.
Symptoms to watch out for parents:
- Abundant regurgitation. In quantitative terms - from half to the full volume that was introduced in one feeding, especially if this situation is repeated in more than half of the feedings.
- The child has insufficient weight gain. A very formidable sign is the loss of body weight from the original and / or a decrease in the number of urination of the child less than 8 - 10 times a day.
- There are certain symptoms associated with the broncho-pulmonary system, recurrent cough, especially the occurrence of pneumonia in children of the first six months of life.
- The general condition of the child is disturbed.
- Profuse vomiting of previously eaten food with an admixture of bile (the contents of the vomit becomes yellow), especially if the child does not have a stool.
Which doctors should be contacted to rule out organic diseases that sometimes require immediate medical intervention:
- Pediatrician - Your first assistant, having assessed the condition of the child, will be able to say whether your worries were in vain or it is still necessary to show the baby to others specialists, as well as prescribe treatment, if necessary.
- A neurologist, as a number of neurological problems that occur in a small child can also be accompanied by regurgitation (hydrocephalic syndrome, perinatal damage to the central nervous system).
- Pediatric surgeon. Some of the diseases, one of the signs of which may be vomiting, require emergency surgical intervention (pyloric stenosis, intestinal obstruction).