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Spitting Up: Is it Reflux?
By Anne Smith - IBCLC
Almost all babies will spit up after some feedings, whether they are breastfed
or bottle-fed. In a healthy baby who is gaining weight well and has good urine
and stool output (6-8 wet cloth diapers or 5-6 disposable) and at least 3 bowel
movements in 24 hours (in babies over 6 weeks old, stooling less often is normal),
then spitting up is more of a laundry problem than a medical problem.
Babies spit up for lots of reasons, including gagging when the milk lets down
quickly and forcefully, oversupply of milk, immature muscle control, allergy,
and disease. Many times the reason for the spitting up can't be determined.
Most healthy babies will outgrow the spitting up stage within 4-6 months.
If your baby seems happy and is growing normally, try these tips for minimizing
spitting up:
- Handle him gently and burp him
often.
- Try to keep him in an upright
position during and after feedings. Nurse frequently. Smaller, more frequent
feedings are easier to digest.
- Keep clean - up supplies (a cloth
diaper to throw over your shoulder is a necessity) and a change of clothes
nearby.
- If you have tons and tons of milk,
and your baby chokes or gags when the milk lets down, then spits up afterward,
try offering one breast per feeding. You may also try taking him off the breast
when the milk first lets down and catching the forceful spray in a towel,
then putting him back on the breast after the initial flow of milk has subsided.
For more suggestions on handling an overabundant milk supply, see the article
on "Oversupply: Too Much Milk".
- If your baby wants to nurse constantly,
and seems to spit up every time he eats, try offering a pacifier -that may
keep him from overfilling his stomach and spitting up the excess. If he isn't
gaining weight well and getting him to nurse is a struggle, forget the pacifier.
He needs to spend all his sucking time at the breast.
If you are giving him supplemental
vitamins, iron, or fluoride, try discontinuing them. Most breastfed babies don't
need vitamin supplements. If you are taking herbal or vitamin supplements, try
stopping and see if it makes a difference. If your baby is receiving supplemental
formula or has just started eating a new food, stop offering it. If
you are eating a lot of dairy products, or if you have a family history of allergies,
try cutting back or eliminating allergenic foods like milk, eggs, or wheat.
It takes up to two weeks to completely eliminate milk protein from your milk,
so allow that much time before you decide if it has made a difference.
Sometimes babies have a number of symptoms in addition to spitting up which
may indicate a problem called "gastroesophageal reflux", also called
GER, or just "reflux". Reflux occurs when the muscle at the opening
of the stomach (which keeps milk in the stomach until it is empties into the
small intestine) opens up at the wrong times, causing the milk to back up into
the esophagus (the tube that leads from the throat to the stomach). The gastric
juices are acidic, and can burn and irritate the throat and esophagus.
The newborn's stomach is small (about the size of a golfball) and has to accommodate
a large volume of milk in relation to its size. Most babies who spit up are
just messy eaters, and the excess milk they take in comes back up. The spitting
up disappears without treatment as they mature.
There is another condition that can cause symptoms of vomiting in infants, and
is more severe than reflux. It is pyloric stenosis, and is seldom seen in breastfed
babies. It is most common in male infants, and usually develops 4-6 weeks after
birth. The baby often projectile vomits, which means that his stomach muscles
force the milk up his throat and it shoots forcefully out of his mouth, sometimes
as far as several feet away. As time goes on, he will begin projectile vomiting
after every feeding, and will not gain weight well. This condition is usually
treated with a simple surgery (called pyloromyotomy). Occasional projectile
vomiting doesn't mean the baby has pyloric stenosis, but if it occurs once a
day or more, you should have your baby checked by his doctor.
Reflux in adults causes heartburn. Symptoms of reflux in infants may include
sudden, inconsolable crying; refusing to nurse, or wanting to nurse 'constantly';
difficulty swallowing; vomiting hours after eating; frequent sore or irritated
throat; breathing difficulties, such as wheezing, bronchitis, labored breathing
or apnea; disruption of sleep patterns, or slow weight gain. Many healthy, normal
babies will have some of these symptoms without having reflux. Reflux is not
usually considered a problem unless the baby is really hurting and miserable,
is not gaining weight, has choking episodes, or is experiencing complications
from aspirated fluid or inflamed tissue in his esophagus. In most cases, treatment
of reflux focuses on helping your baby be more comfortable while his digestive
system has time to mature. Many babies with symptoms of reflux show great improvement
by the middle of the first year, and outgrow it completely by one year, although
sometimes it takes longer.
Research has shown that breast-fed babies have fewer and less severe episodes
of reflux than formula-fed babies. Breast milk is more easily digested than
formula, and is emptied from the baby's stomach twice as quickly. The less time
the milk spends in the stomach, then the less opportunity it has to back up
into the esophagus. Any delay in stomach emptying can aggravate reflux. Because
human milk is digested so quickly, more milk can be absorbed in a shorter amount
of time, even if it does come back up.
Another advantage of breastfeeding the baby with reflux is that human milk is
less irritating to the esophagus than formula, and has a lower acidity, so if
the baby does aspirate it, it causes less burning. Breastfed baby's spit-up
also has a much less offensive smell than a formula-fed baby's, and it is less
likely to stain clothing.
Another advantage of nursing the baby with reflux is the closeness between mother
and baby. When your baby is in pain or unhappy, it is easy to become overwhelmed
and stressed out. Nursing gives you a built in way to comfort your baby, and
the hormones produced when you breastfeed help you relax while dealing with
a very fussy baby. Nursing helps you respond to your baby's cues, and while
you can't always eliminate his discomfort or make him happy, it is important
for you to be there to comfort him, and nursing (with the closeness and body
contact that it involves) is the very best way to do that.
Once the diagnosis of reflux is made (usually based on the mom's description
of her baby's behavior, but often doctors with give the baby a radioactive isotope
in milk and track the passage of the milk - breastmilk can be used for this
test, and given by dropper or cup if the baby won't take a bottle) and other
medical problems such as lung disease, asthma, or pyloric stenosis are ruled
out, treatment options vary. Usually the first thing to try is upright positioning
during and after feedings. Some baby seats can aggravate reflux because they
bend the baby's middle and put pressure on his stomach. Using a front carrier
or baby sling, elevating the crib at a 45 degree or greater angle, or letting
him sleep upright on your chest are good alternatives. The next thing is to
try to identify foods or vitamins in the mother or baby's diet that might be
causing a reaction. In the past, it was often recommended that mothers add cereal
to thicken their baby's feedings. The theory was that thicker food would have
a harder time bouncing back up into the esophagus. This method has not been
shown to be effective, and can interfere with breastfeeding. It can also cause
more irritation to the baby's esophagus if it is aspirated, and is not commonly
used today.
If these measures don't work, the next step is to try medicine to reduce stomach
acid and help speed up the time that it takes for the milk to pass into the
baby's intestines. A commonly used medication is Zantac (which reduces stomach
acid). Surgery is a last resort, and is reserved for severe cases with dangerous
complications, and only after all other treatment has failed.
One common challenge to overcome when dealing with reflux is that since the
baby experiences pain when he eats, he may decide he doesn't want to nurse.
This can be terribly frustrating for both you and your baby, and can result
in low weight gain. If he needs to be supplemented, you can pump after feedings
to get high calorie hindmilk and supplement with that instead of formula. If
you don't want to use bottles, see the article on "Introducing Bottles
and Pacifiers to the Breastfed Baby" for information on alternate feeding
methods.
Techniques on encouraging your baby to nurse include:
- Minimize distractions and keep
feedings as peaceful and calm as possible. Nurse in a quiet, dark room
and play soothing music.
- Try nursing when he is sleepy.
Babies with reflux tend to wake more often, so take advantage of this
hance to get extra feedings in. Keep him close to you during the night.
- Give him lots of skin-to-skin
contact and cuddling. Try nursing him in a warm bath.
- 4) Practice with different positions,
and try nursing while standing and walking around. Baby slings are great
for this, and help keep the baby upright while your hands are free.
Experiment with these suggestions, because what works for one baby may not work
for another. Work closely and communicate with your baby's health care providers,
because treatment of reflux can require adjusting medications and trying different
options until you find what works for your baby.
Be sure that you have lots of support and help for you and your family while
you are dealing with the stress of an unhappy baby. Ask for help! Let someone
bring you meals or take your older kids for a while. A great support group for
parents dealing with reflux is PAGER (Pediatric/Adolescent Gastroesophageal
Reflux Association). PAGER is a national organization that provides information
and support to families who have children with reflux. They have brochures,
hold monthly meetings, and publish a monthly newsletter. Their website address
is www.reflux.org.
If your baby has reflux, try to keep a positive attitude, and remember that
in almost all cases, spitting up and reflux occurs in healthy babies who just
need a little more time to grow. Before you know it, your fussy baby will be
a teenager and getting his driver's license, and then you'll really have something
to worry about!
About the Author
Anne Smith, anne@breastfeeding-basics.com
http://www.breastfeeding-basics.com
Anne Smith is an IBCLC – International Board Certified Lactation Consultant
and La Leche Leader since 1978. More importantly, she is a mother to 6 breast
fed kids with twenty plus years experience of counseling nursing mothers. Her
site, www.BreastfeedingBasics.com
, provides expert advice and solutions to breast-feeding problems and gives
basic information on how to breast feed. Anne also features her recommended
breast feeding products and breast pumps.
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if you have any questions or comments!