Reflux or Normal Spit-up: How To Tell the Difference & What To Do
Updated: Jan 18, 2021
Spit-up or Reflux
Does your baby spit-up or vomit after feeds? This is a common problem and a common cause for concern for parents. Here are some tips on how to know if your baby's spit-up is normal or if it's something you need to be worried about.
First, know that ALL babies spit up at least some of the time and most baby spit-up is normal. Here are some signs that let you know your baby's spit up falls into this normal category:
Your baby spits up only some of the time and not with every feed.
Your baby is generally happy, unbothered, or sleeping without awakening when he/she spits up.
Your baby's weight is normal and they are continuing to gain good weight. (This means that even if the spit-ups seem to be large, your baby is holding down far more milk than they are spitting up, evident in the fact that they are still growing appropriately.)
If your baby fits all three of these, read no further. Your baby is fine, their spit-ups are normal, and there's no need to worry. Yay!
However, if your baby does not meet all of the above criteria, read on!
If your baby falls into any of the below categories, it is more likely that you should be concerned:
Your baby spits up after every single feed.
Your baby is fussy, agitated, or seems very uncomfortable when he/she spits up, which may include arching his/her back.
Your baby was born prematurely (before 37 weeks).
Your baby's weight is lower than normal or your baby is not gaining enough weight (find out from your child's doctor if this is the case).
If your baby falls into one or more of these categories, true reflux is more likely. So let's dive in a little more.
What is reflux?
Reflux, also known as acid reflux or GERD (gastroesophageal reflux disease), is when contents of the stomach come back up into the esophagus, and sometimes into the mouth in the form of spit-up or vomit. Because the stomach contains acid to help break down food, this backup of acidic stomach contents can sometimes cause irritation and pain, resulting in a baby who is fussy or cries with spit-ups.
What causes reflux?
In infants, there is a muscle between the esophagus and the stomach that keeps stomach contents in the stomach where they belong. However, this muscle is not very strong yet in babies, especially in premature infants.
In addition, babies spend most of their time lying flat on their backs and their diet is made up of only liquids (at least until starting solids or baby foods). This in combination with a weak muscle creates an environment where reflux commonly occurs.
What can you do about your baby's reflux?
Treatment for reflux depends on severity. Reflux, regardless of severity, generally resolves on its own by one year of age but may require intervention before that time if it is causing problems for your baby. Now let's break down reflux by severity.
If your baby spits up after every single feed but does not seem bothered by this and is gaining good weight, your baby likely has mild reflux. Here are your treatment options for mild reflux:
Check for Overeating/Overfeeding
Consider the possibility that your baby is being overfed or is overeating, especially if your baby takes milk (formula or breastmilk) from a bottle. A full-term newborn stomach is only about the size of a ping-pong ball. This means that most newborn babies will only eat about 1 to 2 ounces (30-60 mL) per feed, and may be less if your baby was born prematurely. If your baby is eating more than their stomach can hold, the excess milk will have nowhere else to go and will come back up as spit-up or vomit.
After the newborn period, there is no magic number of how much your baby should be eating and you should allow your baby to dictate how often you increase the volume of their feeds by looking for continued signs of hunger after they finish their usual amount. However, you should only increase feeds by 0.5 to 1 ounce (15-30 mL) at a time to avoid overfeeding your baby.
If you think your baby could be overeating or be overfed (and your baby is gaining good weight), try decreasing their feeds by 0.5 ounces (15 mL) and see if this improves or stops your baby's spit-ups. If it does help, talk to your baby's doctor before decreasing their feeds any further.
Burp Your Baby Well
Make sure to burp your baby well after (and sometimes, during) feeds. Babies swallow air as they feed and these air bubbles sometimes trap milk above them, which can cause a spit-up when that bubble pops. If your baby spits up often, burping your baby more frequently, at least every 5-10 minutes or after every 1-2 ounces of milk, during a feed, can help to prevent the buildup of these air bubbles and can help prevent spit-ups and fussiness.
To burp your baby, put them in an upright position. This is usually easiest over your shoulder. Make sure you have a good hold on your baby, then firmly pat his/her back to help air bubbles to rise.
Prop Your Baby Up at an Angle
Since lying flat can lead to more chances of reflux, prop your baby up a slight angle (using a baby chair, swing, carseat, or a pillow under supervision) for 15-20 minutes after feeds rather than laying them on their back right away. This allows gravity to help your baby's milk stay down in the stomach where it should be.
If your baby does seem bothered by their spit-ups (fussy, agitated, uncomfortable, or arching his/her back) but is still gaining good weight, your baby likely has moderate reflux. Here are your treatment options for moderate reflux:
All of the Above
You can try all of the things listed above in the mild reflux section. However, your baby may need a little more help.
You can try thickening your baby's feeds with infant cereal. This is the one circumstance where cereal in the bottle rather than on the spoon is okay. Opt for whole wheat, oatmeal, quinoa, or other high-fiber varieties or infant cereal to prevent constipation that often occurs with standard rice cereal.
Start with 1 teaspoon of cereal per ounce of milk (for example, add 3 teaspoons of cereal to a 3 ounce bottle of milk). If this improves your baby's spit-ups but your baby is still spitting up some, you can add more cereal as needed up to 1 tablespoon (equivalent to 3 teaspoons) per ounce of milk.
Keep in mind that the more cereal you add, the thicker the milk will become and you may have to move to the next stage nipple (for example, change from a newborn to a 6-month nipple or from a slow-flow to a medium-flow nipple) to accommodate the thicker milk. This is recommended over trying to make your own larger opening in your baby's nipple.
If your baby is spitting up regularly, is fussy or uncomfortable with spit-ups, AND is not gaining enough weight, your baby likely has severe reflux. Here are your treatment options for severe reflux:
All of the above suggestions may help a little with severe reflux but your baby will likely still have issues. DO NOT DECREASE THE VOLUME OF YOUR BABY'S FEEDS IF YOUR BABY IS NOT GAINING GOOD WEIGHT.
If your baby has severe reflux, your baby's doctor will most likely prescribe an anti-reflux medication. These medications are meant to neutralize stomach acid. This will decrease or stop the pain and irritation (and fussiness) associated with your baby's spit-ups but will not necessarily decrease the amount of spit-up. Talk to your child's doctor about which type of anti-reflux medication they recommend.
SPECIAL NOTE ABOUT MEDICATION: In April 2020, The FDA (Food and Drug Administration) requested that ranitidine (brand name Zantac) be removed from the U.S. market due to unacceptable levels of a probable cancer-causing chemical found in some ranitidine products. If your baby has been prescribed ranitidine, talk with your doctor right away to discuss switching to a safer alternative.
Remember, most importantly, reflux will improve on its own with time. But now you have the tools to help your baby up until then when necessary.
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