New parents often ask me about their baby’s spitting up. “What or how much is normal?” “When should I get concerned?” These are often difficult questions to answer because reflux is normal to a certain degree in everyone of any age, especially in infants. GER, which is short for gastroesophageal reflux, is characterized by the sensation of food or fluids moving from the stomach into the esophagus and may be associated with a burning discomfort in the chest, sour taste in the mouth or cough. When GER leads to complications, it is called GERD (gastroesophageal reflux disease). Rarely is GERD diagnosed in an infant, but when it is the complications may include esophagitis, poor weight gain or lung complications. GER turns into GERD often over a long period of time.
Infants normally experience reflux 10 to 50 times a day. Regurgitation peaks at 4 months of age and tends to improve slowly thereafter. When discussing reflux it is important to know the amount the infant is spitting up. Often parents will tell me their baby is spitting up everything that he or she eats. A normal infant at 2 weeks old eats about two ounces of fluid. At this point I encourage parents to pour two ounces of water on the floor to give them a perspective of truly how much fluid is present. Then we discuss the quality of the spit-up: does the liquid run down the burp rag, shoot across the room or happen only when the infant is burped at the end of a feeding.
It is suggested that infants be given a chance to burp halfway through drinking a bottle or more frequently if they are heavy feeders and frequently spit up. Yet if the infant is gaining weight and lacking any major warning signs (including but not limited to forceful vomiting, blood in the stools or vomit, abdominal pain indicated by crying inconsolably) then there is not likely anything wrong with the infant. The best approach is conservative treatment with reassurance and frequent rechecks by the physician for appropriate weight gain and examination.
Further investigation into the cause of the spitting up and referral to a specialist may be in order if a warning sign is present. However, warning signs are present in a very small fraction of infants who have reflux. The biggest problem I have noticed, speaking from a personal and professional aspect, is the interference with normal family life when an infant is spitting up a lot and is irritable due to GER. There have been very few quality studies linking irritability and esophageal pain associated with reflux.
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Possible interventions when reflux appears to be bothering the infant are numerous. A commonly attempted intervention is eliminating milk proteins by switching to soy formula or, if breastfeeding, removing dairy products from the mother’s diet. Some studies estimate that up to 40 percent of GER babies have protein intolerance. Before discontinuation of breastfeeding or formula changes occur, a physician should be consulted.
Often parents attempt to thicken the formula with rice cereal to reduce reflux. Although studies do support that this helps, no scientific data exists that it actually decreases the amount or severity of refluxing. Discuss with your physician how much rice cereal to add to the formula in order to prevent your baby from getting too many calories.
Although the belly sleeping position tends to reduce reflux, it is associated with a higher risk for sudden infant death syndrome (SIDS). Therefore, regardless of the amount of reflux, babies should sleep on their backs. Placing the infant to sleep in a car seat or lying on his or her side do not relieve GER symptoms.
When all else fails, medications may be of benefit. The most commonly used and studied medications are proton pump inhibitors such as Prevacid or Prilosec. Medications to stimulate bowel movement, including Reglan, are only used as a last resort due to substantial side effects and limited improvement in the quality of life.
Infants will always spit up, and this is normal to a degree. Look for the warning signs of a problem and discuss them with your physician. Although it is difficult to hear, the reflux will go away. It just may take four months and a lot of changing shirts and sleep-deprived nights to get to that point.