Spitting Up & Reflux in the Breastfed Baby

By Kelly Bonyata, BS, IBCLC

My baby spits up – is this a problem?

Spitting up, sometimes called physiological or uncomplicated reflux, is common in babies and is usually (but not always) normal. Most young babies spit up sometimes, since their digestive systems are immature, making it easier for the stomach contents to flow back up into the esophagus (the tube connecting mouth to stomach).

Babies often spit up when they get too much milk too fast. This may happen when baby feeds very quickly or aggressively, or when mom’s breasts are overfull. The amount of spitup typically appears to be much more than it really is. If baby is very distractible (pulling off the breast to look around) or fussy at the breast, he may swallow air and spit up more often. Some babies spit up more when they are teething, starting to crawl, or starting solid foods.

A few statistics (for all babies, not just breastfed babies):

• Spitting up usually occurs right after baby eats, but it may also occur 1-2 hours after a feeding.
• Half of all 0-3 month old babies spit up at least once per day.
• Spitting up usually peaks at 2-4 months.
• Many babies outgrow spitting up by 7-8 months.
• Most babies have stopped spitting up by 12 months.

If your baby is a ‘Happy Spitter’ –gaining weight well, spitting up without discomfort and content most of the time — spitting up is a laundry & social problem rather than a medical issue.

Some causes of excessive spitting up

• Breastmilk oversupply or forceful let-down (milk ejection reflex) can cause reflux-like symptoms, and usually can be remedied with simple measures.

• Food sensitivities can cause excessive spitting. The most likely offender is cow’s milk products (in baby’s or mom’s diet). Other things to ask yourself: is baby getting anything other than breastmilk – formula, solids (including cereal), vitamins (fluoride, iron, etc.), medications, herbal preparations? Is mom taking any medications, herbs, vitamins, iron, etc.?

• Babies with Gastroesophageal Reflux Disease (GERD) usually spit up a lot (see below).

• Although seldom seen in breastfed babies, regular projectile vomiting in a newborn can be a sign of pyloric stenosis, a stomach problem requiring surgery. It occurs 4 times more often in boys than in girls, and symptoms usually appear between 3 and 5 weeks of age. Newborns who projectile vomit at least once a day should be checked out by their doctor.

My older baby just started spitting up more – what’s up?

Some older babies will start spitting up more after a period of time with little or no spitting up. It’s not unusual to hear of this happening around 6 months, though you also see it at other ages. If the spitting up is very frequent (particularly if baby does not seem well), consider the possibility of a GI illness.

If baby does not seem ill, then here are some possible causes:

• It’s unlikely that your baby has suddenly developed a sensitivity to something in your milk, unless there’s something really new in your diet or you’re eaten LOTS of a particular food very recently. Any foods that baby eats are more likely than mom’s foods to cause the spitting up. Has baby started solids recently or tried a new food? Are you or baby taking any new medications? Have you or baby started taking vitamins or changed your vitamins?
• Has baby been fussier than normal, and/or crying more lately? If so, he is probably swallowing more air than usual, which can cause the spitting up.
• Spitting up can be caused by teething. When teething, babies tend to drool more and often swallow a lot of that extra saliva – this can cause extra spitting up.
• A cold or allergies can result in baby swallowing mucus and spitting up more.
• Baby may be hitting a growth spurt and swallowing more air when he nurses, especially if he’s been “guzzling” lately.
• If you tend to have oversupply or a fast let-down, some moms see renewed symptoms (which can include spitting up) after a growth spurt.

Essentially, though, if your baby is healthy and doing well despite the spitting up — gaining well, having enough wet/dirty diapers — then this is a laundry problem rather than a medical issue.

Gastroesophageal Reflux Disease (GERD)

A small percentage of babies experience discomfort and other complications due to reflux – this is called Gastroesophageal Reflux Disease. These babies have been termed by some as ‘Scrawny Screamers’ (as compared to the Happy Spitters). There seems to be a family tendency toward reflux. GERD is particularly common in preemies (due to their immaturity) and in babies with other health problems. GERD usually improves by 12-24 months.

Following are symptoms of GERD — there are varying degrees and need your doctor’s involvement to diagnose:

• Frequent spitting up or vomiting; discomfort when spitting up. Some babies with GERD do not spit up – silent reflux occurs when the stomach contents only go as far as the esophagus and are then re-swallowed, causing pain but no spitting up.
• Gagging, choking, frequent burping or hiccoughing, bad breath.
• Baby may be fussy and sleep less due to discomfort.

Warning signs of severe reflux:

• Inconsolable or severe fussiness or crying associated with feedings.
• Poor weight gain, weight loss, or failure to thrive. Difficulty eating. Breast/food refusal.
• Difficulty swallowing, sore throat, hoarseness, chronic nasal/sinus congestion, chronic sinus/ear infections.
• Spitting up blood or green/yellow fluid.
• Sandifer’s syndrome: Baby may ‘posture’ and arch the neck & back to relieve reflux pain–this lengthens the esophagus and reduces discomfort.
• Breathing problems: bronchitis, wheezing, chronic cough, pneumonia, asthma, aspiration, apnea, cyanosis.

GERD may cause babies to either undereat (if they associate feeding with the after-feeding pain, or if it hurts to swallow) or overeat (because sucking keeps the stomach contents down in the stomach and because mother’s milk is a natural antacid).

Current information on reflux indicates that testing or treatment for reflux in babies younger than 12 months should be considered only if spitting up is accompanied by poor weight gain or weight loss, severe choking, lung disease or other complications. Per Donna Secker, MS, RD in the article Gastroesophageal Reflux Disease, “The infant with significant reflux who seems to be growing well and has no other significant health problems benefits most from little or no therapy.”

When GERD is suspected, many doctors first try a trial of various reflux medications (without running tests), to see if the medications improve baby’s symptoms. If testing is done, a 24-hour pH probe study () is the current “gold standard” for reflux testing in babies; this is a procedure where a tube is placed down baby’s throat to measure the acid level at the bottom of the esophagus. A barium swallow (upper GI) is not so invasive (baby swallows a barium mixture, then an x-ray is taken) but is not really effective for diagnosing reflux in babies, since most babies will reflux when given barium. An upper GI will not identify whether baby’s stomach contents are higher in acid or if there has been any esophagus damage due to reflux, but it will show if there are any blockages or narrowing of the stomach valves that may be causing or aggravating the reflux. Additional tests may be recommended in certain circumstances (see the links below for additional information). In rare cases, when baby has very severe reflux that is not relieved by medication, surgery may be recommended.

Breastfeeding Tips

• Aim for frequent breastfeeding, whenever baby cues to feed. These smaller, more frequent feedings can be easier to digest.
• Try positioning baby in a semi-upright or sitting position when breastfeeding, or recline back so that baby is above and tummy-to-tummy with mom. See this information on upright nursing positions.
• For fussy, reluctant feeders, try lots of skin to skin contact, breastfeeding in motion (rocking, walking), in the bath or when baby is sleepy.
• Ensure good latch to minimize air swallowing.
• Allow baby to completely finish one breast (by waiting until baby pulls off or goes to sleep) before you offer the other. Don’t interrupt active suckling just to switch sides. Switching sides too soon or too often can cause excessive spitting up (see Too Much Milk?). For babies who want to breastfeed very frequently, try switching sides every few hours instead of at every feed.
• Encourage non-nutritive/comfort sucking at the breast, since non-nutritive sucking reduces irritation and speeds gastric emptying.
• Avoid rough or fast movement or unnecessary jostling or handling of your baby right after feeding. Baby may be more comfortable when help upright much of the time. It is often helpful to burp often.
• As always, watch your baby and follow his cues to determine what works best to ease the reflux symptoms.

What can I do to minimize spitting up/reflux?

• Breastfeed! Reflux is less common in breastfed babies. In addition, breastfed babies with reflux have been shown to have shorter and fewer reflux episodes and less severe reflux at night than formula-fed babies [Heacock 1992]. Breastfeeding is also best for babies with reflux because breastmilk leaves the stomach much faster [Ewer 1994] (so there’s less time for it to back up into the esophagus) and is probably less irritating when it does come back up.
• The more relaxed your infant is, the less the reflux.
• Eliminate all environmental tobacco smoke exposure, as this is a significant contributing factor to reflux.
• Reduce or eliminate caffeine. Excessive caffeine in mom’s diet can contribute to reflux.
• Allergy should be suspected in all infant reflux cases. According to a review article in Pediatrics [Salvatore 2002], up to half of all GERD cases in babies under a year are associated with cow’s milk protein allergy. The authors note that symptoms can be similar and recommend that pediatricians screen all babies with GERD for cow’s milk allergy. Allergic babies generally have other symptoms in addition to spitting up.
• Positioning:
  • Reflux is worst when baby lies flat on his back.
  • Many parents have found that carrying baby in a sling or other baby carrier can be helpful.
  • Avoid compressing baby’s abdomen – this can increase reflux and discomfort. Dress baby in loose clothing with loose diaper waistbands; avoid “slumped over” or bent positions; for example, roll baby on his side rather than lifting legs toward tummy for diaper changes.
  • Recent research has compared various positions to determine which is best for babies with reflux. Elevating baby’s head did not make a significant difference in these studies [Carroll 2002, Secker 2002, Craig 2004], although many moms have found that baby is more comfortable when in an upright position. The positions shown to significantly reduce reflux include lying on the left side and prone (baby on his tummy). Placing the infant in a prone position should only be done when the child is awake and can be continuously monitored. Prone positioning during sleep is almost never recommended due to the increased SIDS risk. [Secker 2002]
  • Although recent research does not support recommendations to keep baby in a semi-upright position (30° elevation), this remains a common recommendation. Positioning at a 60° elevation in an infant seat or swing has been found to increase reflux compared with the prone (tummy down) position [Carroll 2002, Secker 2002].
  • As always, experiment to find what works best for your baby.
• If your child is taking reflux medications, keep in mind that dosages generally need to be monitored and adjusted frequently as baby grows.

What about thickened feeds?

Baby cereal, added to thicken breastmilk or formula, has been used as a treatment for GER for many years, but its use is controversial.

Does it work? Thickened feeds can reduce spitting up, but studies have not shown a decrease in reflux index scores (i.e., the “silent reflux” is still present). Per Donna Secker, MS, RD in Gastroesophageal Reflux Disease, “The effect of thickened feedings may be more cosmetic (decreased regurgitation and increased postprandial sleeping) than beneficial.” Thickened feeds have been associated with increased coughing after feedings, and may also decrease gastric emptying time and increase reflux episodes and aspiration. Note that rice cereal will not effectively thicken breastmilk due to the amylase (an enzyme that digests carbohydrates) naturally present in the breastmilk.

Is it healthy for baby? If you do thicken feeds, monitor baby’s intake since baby may take in less milk overall and thus decrease overall nutrient intake. There are a number of reasons to avoid introducing cereal and other solids early. There is evidence that the introduction of rice or gluten-containing cereals before 3 months of age increases baby’s risk for type I diabetes. In addition, babies with GERD are more likely to need all their defenses against allergies, respiratory infections and ear infections – but studies show that early introduction of solids increases baby’s risk for all of these conditions.

The breastfeeding relationship: Early introduction of solids is associated with early weaning. Babies with reflux are already at greater risk for fussy nursing behavior, nursing strikes or premature weaning if baby associates reflux discomfort with breastfeeding.

Safety issues: Never add cereal to a bottle without medical supervision if your baby has a weak suck or uncoordinated sucking skills.

 

Additional Information

Spitting Up: Is it Reflux? by Anne Smith, IBCLC

LLL FAQ on breastfeeding and reflux

Gastroesophageal Reflux in Young Children by Pamela Tyler, M.S., CCC SLP

The Children’s Digestive Health and Nutrition Foundation (CDHNF)

NASPGHAN Guidelines on Pediatric GERD and Guidelines Summary on Pediatric GERD from the Children’s Digestive Health and Nutrition Foundation (CDHNF)

North American Society for Pediatric Gastroenterology and Nutrition (NASPGHAN)

 

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