Baby spit up, reflux and when vomiting is something serious

Almost every baby brings up milk, and in a baby who is feeding well and gaining weight, it is normal. Doctors call this reflux, and it usually fades by the first birthday. Most of these babies need no medicine at all. A few kinds of vomiting, though, are an emergency, and every parent should know them.

Is it normal for my baby to spit up after feeds?

Yes. Bringing up milk after feeds is very common in healthy babies and usually needs no tests or treatment.¹

In a survey of nearly 1,000 families, half of babies aged 0 to 3 months spat up at least once a day.² UK guidance puts the figure at 40% or more of all babies, and says it usually starts before 8 weeks of age.¹ Some babies spit up 6 or more times a day and are still perfectly healthy.¹

Doctors call this a "happy spitter": a baby who brings up milk, sometimes a lot, but feeds well, gains weight and is not in pain. The main problem is the washing. Keep a pile of muslin cloths ready.

Why do babies spit up so much?

Because a baby's food pipe is short, her stomach is small, and her diet is all liquid. Some milk is bound to come back up.

Reflux (gastro-oesophageal reflux) means stomach contents moving back up into the food pipe (oesophagus). It happens in adults too, but we rarely notice it.¹ In babies, the ring of muscle at the bottom of the food pipe relaxes often. The baby lies down for much of the day. A large feed then fills a small stomach. Some of it comes back.

The spit-up often looks curdled and smells sour. That is just stomach acid acting on milk. It does not mean the milk has gone bad or disagrees with her.

When will my baby stop spitting up?

Spitting up usually peaks around 4 months, drops a lot after 6 months, and stops in most babies by 12 months.^2,1

In the survey, 67% of babies were spitting up daily at 4 months. This fell to 21% at 7 months and 5% at 10 to 12 months.² UK guidance says it settles before the first birthday in about 90% of affected babies.¹

Sitting up, eating solids and walking all help. If spitting up continues often after 1 year, or first starts after 6 months, your doctor should look for another cause.¹

What is the difference between reflux and reflux disease (GERD)?

Reflux is the normal spitting up seen in most babies. Reflux disease (GORD or GERD) means the reflux is causing real harm or marked distress.¹

Signs that reflux may be causing a problem include:

• poor weight gain, or weight loss
• refusing feeds, or real distress with most feeds
• blood in the vomit
• breathing problems linked with feeds, or repeated chest infections

Reflux disease affects only a small share of babies who spit up.¹ Crying and back arching alone are common in healthy babies and do not prove reflux disease. In trials, acid medicines did not improve crying or arching more than placebo.³

Is my baby getting enough milk if she spits up a lot?

If she is gaining weight well and has plenty of wet nappies, she is getting enough, however much ends up on your shoulder.

Spit-up almost always looks like more than it is. Pour a spoonful of milk on a cloth and see how far it spreads. Weight is the best guide. Ask for her weight to be checked at her vaccine visits and plotted on her growth chart.

Be concerned if she has fewer wet nappies, refuses feeds, seems in pain with most feeds, or her weight falls across the lines on her chart. Poor growth together with spitting up needs a doctor's review.¹

Does my baby need antacid or reflux medicine?

Almost never for spitting up alone. UK guidance says not to give acid-blocking medicines for regurgitation when it is the only symptom.¹

Joint North American and European guidelines also advise against them for crying or distress alone in otherwise healthy babies.³ Trials explain why:

• In 162 babies with reflux symptoms, lansoprazole worked no better than placebo. Exactly 54% improved in each group.⁴
• In irritable babies with reflux, omeprazole lowered acid but did not reduce crying any more than placebo.⁵

Dr Dutta does sometimes use these medicines, for a set trial of a few weeks, when there is good reason to think acid is causing harm. But for a thriving baby who spits up, her answer is no.

Are reflux medicines safe for babies?

They are not harmless. Stomach acid helps protect against germs, and blocking it has costs.

In the lansoprazole trial, serious side effects, mainly chest infections, happened more often in babies on the drug than on placebo.⁴ UK guidance also notes drug safety warnings for this group of medicines, including low magnesium and a higher risk of fractures with long-term use.¹

If your baby is already on an antacid for simple spitting up, do not stop it suddenly on your own. Talk to your paediatrician about whether it is still needed.

How can I reduce my baby's spit-up?

For a formula-fed baby, first check she is not being overfed, then try smaller, more frequent feeds with the same total amount.¹

• Ask your doctor whether her bottles are larger than she needs for her weight. If they are, reducing them is the first step.¹
• Try smaller feeds, more often, for a week or two.¹
• For a breastfed baby with distress, ask for a breastfeeding check of latch and position.¹
• Hold her upright against your shoulder for a while after feeds.
• Avoid tight nappies and bouncing right after a feed.

What about burping? A trial from Chandigarh found that routine burping did not reduce colic and was linked with more spit-up, not less.⁶ If your baby seems uncomfortable, a gentle burp is fine. You do not need to pat her for 20 minutes.

Does thickened or anti-reflux formula help?

Thickened formula can reduce visible spit-up a little in formula-fed babies, but it does not reduce the amount of acid reflux.⁷

A review of 14 trials found that thickened formulas helped more babies stop spitting up and slightly reduced the number of episodes.⁷ UK guidance suggests a trial of thickened formula only after feed size and frequency have been sorted out.¹

Please do not add rice cereal, suji or biscuit powder to the bottle at home. It changes the calories, can block the teat, and makes the flow unpredictable. If thickening is needed, your doctor will suggest a ready-made anti-regurgitation formula.

Should I raise the cot or let my reflux baby sleep on her tummy?

No. Babies with reflux should sleep flat on their backs, like every other baby.^1,8

Lying on the tummy may reduce reflux a little, but it raises the risk of sudden infant death far more. UK guidance says sleep position should not be used to treat reflux.¹

Wedges, positioners and raised or tilted mattresses have not been shown to help. Products sold to keep a baby in one position or to reduce reflux have been linked to deaths.⁹ Keep the cot flat. Tummy time is for play while she is awake and watched.

Could my baby's spit-up be a milk allergy?

Sometimes. Cow's milk protein allergy is worth thinking about when spitting up comes with blood in the stool, long-lasting diarrhoea, eczema or poor weight gain.¹

In that case your doctor may suggest strictly removing cow's milk protein for a few weeks: from the mother's diet if breastfed, or by changing to a special formula in which the protein is broken down. The milk is then brought back to confirm the diagnosis.¹⁰

Spitting up alone, in a baby who is thriving, is not a reason to stop dairy or change formula.

Is green vomit in a baby an emergency?

Yes. Green or yellow-green vomit (bile) in a baby is an emergency until a doctor proves otherwise. Go to a hospital with children's surgeons straight away.¹

Bile enters the gut below the stomach, so green vomit can mean a blockage in the bowel.¹ The cause we fear most is malrotation with volvulus, where the gut twists on itself and cuts off its own blood supply. In a recent Canadian series, babies with this condition were a median of 7 days old, and the bile in their vomit was sometimes yellow rather than green.¹¹

Not every baby with green vomit needs surgery. In one UK audit, 38% had a surgical cause.¹² But only tests in hospital can tell which group your baby is in. Do not wait to see if it happens again.

What is pyloric stenosis, and what does it look like?

Pyloric stenosis is a thickening of the muscle at the stomach's outlet, so milk cannot pass through. It causes forceful vomiting, usually between 3 and 8 weeks of age.¹³

Boys are affected about four or five times as often as girls. It is most common in firstborn babies and runs in some families.¹³

Signs to watch for:

• vomiting that shoots out forcefully, often across the room, and gets worse over days¹
• milky vomit, not green
• a baby who is hungry and wants to feed again straight after vomiting
• fewer wet nappies, small hard stools and weight loss

An ultrasound confirms it. The treatment is a small operation to split the tight muscle. Once fluids and salts are corrected, the results are excellent, and most babies feed again soon after.

Can antibiotics cause pyloric stenosis?

Yes. Erythromycin and azithromycin taken by mouth in the first weeks of life raise the risk of pyloric stenosis.¹⁴

In a study of over a million babies, the risk was highest when these antibiotics were given in the first 2 weeks of life, and still raised between 2 and 6 weeks.¹⁴ There was no link after 6 weeks.¹⁴

Sometimes these medicines are truly needed, for example for whooping cough. If your young baby has had one, watch for forceful vomiting over the next few weeks and tell your doctor if it starts.

When should I take a vomiting baby to hospital?

Go to an emergency department straight away for any of these:¹

• green or yellow-green vomit
• blood in the vomit, or vomit that looks like coffee grounds
• blood in the stool
• a swollen, tight or tender tummy
• forceful vomiting after every feed
• a floppy, very sleepy or unusually irritable baby
• a bulging soft spot on the head
• fever, or any baby under 3 months with a temperature of 38 degrees C or more
• signs of dehydration: a dry mouth, far fewer wet nappies, a sunken soft spot

Book a routine visit if spitting up starts after 6 months, continues often after 1 year, or comes with poor weight gain, eczema or stool changes.¹ For the happy spitter, a weight check at her next vaccine visit is usually all that is needed.