All babies spit up, some more than others. When it happens after
nearly every feeding, parents often become concerned. They worry that their infant will
not beinhesting enough food to grow or that the infant has something seriously wrong with
their stomach or intestinal tract. If an infant spits up significantly but gains weight,
then it is only messy and a nuisance. After "normal" spitting up, there are
three common conditions that pediatricians diagnosis:
- the baby is allergic to the formula
- the baby has gastroesophageal reflux
- the baby has an area of blockage or narrowing in the intestinal
tract (pyloric stenosis)
Normally, when an infant feeds, swallowing pushes the milk back
into their throat and down into their esophagus. At the bottom of the esophagus there is a
muscle that opens to let nourishment pass into the stomach. The muscle then closes when
the stomach squeezes to push the food into the small intestine. In children with
gastroesophageal reflux, this muscle opens as the stomach squeezes, so food and stomach
acid come up their esophagus and out of their mouth. Other times, the acid and food may
only come part way up, causing the infant to have abdominal pain or gas similar to when an
adult experiences heartburn.
Infants with gastroesophageal reflux are good eaters. Many of them
are "guzzlers" and can not be put off when hungry, finishing their milk very
quickly. Other symptoms of reflux might include sudden or incolsolable crying (from the
stomach acid), general fussiness, bad breath and frequent night waking.
Most of the time, just hearing the parents story and seeing
an otherwise thriving child is enough to complete the diagnosis, but sometimes x-ray
evaluations are recommended. The first test is typically a barium swallow - the baby is
given a small amount of chalky liquid and the radiologist watches as the material is
swallowed and enters the stomach. In children with reflux, the barium can be seen
returning up the esophagus. Other tests, including a pH probe, radioactive scans, and
directly looking into the esophagus with a special scope, are usually performed in severe
cases by a pediatric gastroenterologist.
In most cases, gastroesophageal reflux is self-limiting, which
means the problem will resolve itself by the time the infant is able to sit up (around six
months).Even if the child does not develop problems from their reflux, the condition can
sometimes be difficult to care for and stressful on the family.
Three complications of reflux may occur when the problem is
- Babies can spit up all their feedings causing them not to grow or
gain weight. Malnutrition or "failure to thrive" can result from losing too much
food from the frequent vomiting or from lack of appetite due to pain.
- The stomach acid can irritate the lining of the esophagus causing
inflammation and in severe cases, narrowing of the esophagus
- Babies with reflux can also develop respiratory problems from
stomach contents entering the nose, windpipe or lungs. Many infants are first diagnosed as
having reflux while investigating the cause of recurrent breathing problems such as
wheezing or pneumonia.
Treatment for gastroesophageal reflux includes positioning,
dietary changes, altering feeding schedules, and medications.
Positioning. Babies with reflux need to be
positioned so gravity can help keep the
food from coming back up out of the stomach. The best position to
put the baby after feeding is on their stomach with the head propped up about 30 degrees.
This position causes the stomach to fall forward, closing the valve at the bottom of the
esophagus. Remember, the child should not be allowed to fall asleep in this position
and should always be placed on their side or back when sleeping. Avoid placing the
child in an infant seat or swing since this causes increased pressure on their stomach.
The best approach is to hold the baby quietly for 1/2 hour after feeding.
Dietary Changes. Most infants with
gastroesophageal reflux do better when their feedings are thickened with cereal, making
the feedings heavier and thus less likely to come back up the esophagus. Make the nipple
size larger so babies do not have to suck harder and fill their stomach with air. Infants
who are breast fed may be fed some rice cereal by spoon during or after feedings. In
addition, some reflux babies are more successful on hypoallergenic formulas such as
Alimentum®. Always consult the childs physician before making a change in formula.
Feeding Schedules. Occasionally, feeding the
infant smaller amounts more frequently will help. Unfortunately, these infants are usually
not satisfied with smaller feedings and will cry for more. This causes them to swallow
air, which could make the reflux worse.
Medications. When the above measures do not work,
the infant may be referred to a pediatric gastroenterologist for additional treatment,
including medication. While many different medications may be used to treat reflux, most
of the mediations either neutralize stomach acid (Mylanta, Maalox), reduce acid production
in the stomach (Tagamet, Pepcid, Zantac) or improve intestinal coordination (Reglan,