Dear Dr. Lanny:
Our 8-week-old spits up all the time. I’m beginning to wonder if she’s getting any
formula at all. Could this be esophageal reflux? How do we get her to take in some nutrition?
A: When I was a new parent, babies that spit up frequently, or were particularly irritable, were diagnosed with colic. There was no such thing as gastroesophageal reflux disease.
No one really understood what colic was, but it was diagnosed by the “rule of threes”: The baby was older than three weeks, cried at least three hours per day, and did so at least three times per week. Irritability rather than spitting up was the hallmark of the problem, but they often came as a package. Treatment was varied and of limited value, but most children were better by three months of age.
Miraculously, colic has disappeared. But it has been replaced by gastroesophageal reflux disease (GERD). If your child is spitty or crabby, or both, Nutramigen, Zantac, Axid, or all of the above might be in her immediate future. However, I will argue that much of the strategy of medicating your child is often unnecessary.
What is reflux disease? For that matter, what is spitup, and is it different than vomiting?
Spitup is painless, effortless regurgitation of stomach contents. Spitup tends to occur with, or soon after, feeding. Spitup distresses the parents but doesn’t faze the baby. Vomiting is forceful regurgitation, usually accompanied by distinct discomfort. Vomiting may have no time relation to feeding.
Essentially all babies spit up to some degree in the first months of life. There is no clear definition of how much spitup is too much. If the baby does not seem to be in pain, is not having respiratory symptoms (coughing or wheezing), and is gaining weight in a normal manner, then the spitup is almost certainly not a problem and is not reflux disease.
Feeding the baby in an upright position; keeping the baby somewhat elevated for an hour after feedings; not smoking; and, as always, breast feeding, are the best and safest ways to deal with spitup. Thickening the formula with rice cereal is another treatment that is safe and easy to try (approximately 1 teaspoon of cereal per ounce of formula). Elevating the baby means keeping him on a slant, not fully sitting up, which would squeeze his stomach and aggravate the problem.
Pyloric stenosis is a condition that causes vomiting that parents often describe as being reminiscent of the girl in The Exorcist. It is a problem of very young children (typically around six to eight weeks), is resolved by minor surgery, and is not related to reflux disease.
Gastroesophageal reflux disease, or GERD, includes spitup, but also some type of abnormality. As noted earlier, irritability, unusual arching of the body, coughing, wheezing, or poor weight gain would be symptoms suggesting GERD.
In cases of GERD, the valve at the top of the stomach does not function properly. This allows stomach contents, which are very acidic, to back up into the esophagus (the tube from the mouth to the stomach) or possibly the lungs. The esophagus and lungs are not built to deal with acid, which leads to pain, coughing and wheezing.
Diagnosis is usually based on the clinical picture and response to treatment. If unclear, definitive diagnosis is made by pH probe. For 24 hours, a very thin tube is placed through the nose and positioned just above the stomach. A sensor at the end of the tube measures acid getting out of the stomach. The test is safe and painless.
In some cases the baby may be allergic to the protein in cow’s-milk-based formulas, or even be affected by cow’s milk in a breast-feeding mom’s diet. My boss when I was in training, Dr. Frank Oski, wrote a book called Don’t Drink Your Milk. His point was that cow’s milk is the perfect food. . . if you’re a calf. For humans, this isn’t necessarily the case. Removing dairy products from a breast-feeding mom’s diet, or trying a non-allergenic formula (for example, Nutramigen or Alimentum) may sometimes resolve the problem. These formulas are quite pricey and do not always get the infants’ seal of approval, but they are an easy way to investigate the possibility of milk allergy being the root of the problem.
If positioning or formula changes do not seem to help, your doctor may suggest medication. Medicines that decrease the acid in the stomach, such as Axid or Zantac, are usually recommended. These medications help the symptoms of GERD by decreasing the acid in the spitup, but they do not stop the baby from spitting up.
In severe cases, often in premature infants, surgery may be performed. This is unusual in an otherwise healthy child.
It is fascinating to speculate whether the apparent increase in GERD might at all relate to the “ Back to Sleep” campaign, which began in 1994. Sleeping on the stomach seems to minimize reflux, but is unquestionably linked to increased sudden infant death syndrome, or SIDS.
During the second six months of life, spitting up and associated symptoms tend to decrease naturally. For this reason I strongly recommend hesitating to use medicine unless there are significant problems. The spitty but happy and growing baby may need lots of linens, clothing, and a good washing machine, but not necessarily medications.
Dr. Alan Freshman, father of two grown boys, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.