Infant Spitting Up: When It Is Normal and When It Is Not

Why babies spit up

A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter, normally keeps food in the stomach. In young babies it relaxes often and is still maturing. Babies also have a small stomach, drink a large volume of liquid for their size, spend much of the day lying down, and swallow air while feeding. Milk easily washes back up, especially after a big feed, a burp or a diaper change.

This is gastroesophageal reflux (GER), and in babies it is a normal physical process, not a disease. The amount often looks larger than it is. A tablespoon of milk spread on a muslin cloth looks like a whole feed.

Spitting up vs vomiting

Normal spitting up: the "happy spitter"

Spitting up is normal when your baby:

• is gaining weight along their growth curve
• has at least 6 wet diapers a day after the first week
• feeds eagerly and settles after feeds most of the time
• has no breathing problems, blood or green color in the spit-up

These babies need no tests or medicine. Laundry, not treatment, is the main issue.

Infant GERD: when reflux becomes a problem

Gastroesophageal reflux disease (GERD) is diagnosed when reflux causes troublesome symptoms or complications. Possible signs:

• poor weight gain or weight loss
• refusing feeds, or arching the back and screaming during feeds
• persistent irritability linked to feeding
• chronic cough, wheezing, hoarse voice or recurrent pneumonia
• blood in spit-up, or anemia

Crying and back arching alone are very common in healthy babies, so they are not enough to diagnose GERD. See gastroesophageal reflux disease for how reflux disease is managed at older ages.

Other causes of spitting up and vomiting in babies

• Overfeeding: large volumes or fast-flowing bottles overwhelm a small stomach.
• Cow's milk protein allergy: reflux-like symptoms with eczema, mucus or blood in the stool, diarrhea or poor weight gain. It improves after cow's milk is removed from the baby's formula or the breastfeeding mother's diet.
• Pyloric stenosis: thickening of the stomach outlet at 2 to 8 weeks of age, causing projectile vomiting after every feed and constant hunger. It is more common in first-born boys and is fixed with a short operation.
• Infection: urinary tract infection, gastroenteritis or meningitis can all start with vomiting in a young baby, often with fever or lethargy.
• Bowel blockage or twisting (malrotation with volvulus): green vomit is the key warning sign.
• Intussusception: usually at 6 to 18 months, with episodes of severe crying, drawing up the legs, vomiting and later bloody stool.
• FPIES: repeated, profuse vomiting 1 to 4 hours after a trigger food such as cow's milk, soy, rice or oats, with pallor and floppiness.

How a doctor assesses spitting up

The doctor will ask about the amount and force of spit-up, its color, feeding volume and method, diaper counts, stools, family history of allergy, and how your baby behaves during feeds. They will weigh your baby and plot growth, and examine the belly.

Most babies need no tests. Depending on concerns, a doctor may arrange:

• an ultrasound of the stomach outlet for suspected pyloric stenosis
• urine tests for infection
• an upper GI contrast X-ray for suspected blockage or malrotation
• pH-impedance monitoring or endoscopy in rare, severe or unclear cases

How to reduce spitting up

• Feed smaller amounts more often. Overfeeding is the most common fixable cause.
• Burp during and after feeds, for example every 1 to 2 ounces (30 to 60 ml) for bottle-fed babies.
• Keep your baby upright for 20 to 30 minutes after feeds.
• Avoid pressure on the belly after feeding: loose diapers, no car seat straight after a feed if possible.
• Check the bottle nipple: a flow that is too fast or too slow increases air swallowing.
• Thickened feeds or anti-reflux formula may reduce visible spit-up in formula-fed babies. Discuss with your doctor first.
• Two-to-four-week trial without cow's milk protein (extensively hydrolyzed formula, or maternal dairy avoidance when breastfeeding) if a doctor suspects allergy.

Sleep safety

Always place your baby on their back to sleep on a firm, flat surface. Do not raise the crib mattress, use wedges or positioners, or let your baby sleep in a car seat or swing. Babies with reflux are protected by their airway reflexes and are not at greater risk of choking on their back. Side and tummy sleeping increase the risk of sudden infant death syndrome.

Medicines

Acid-reducing medicines do not reduce spitting up in healthy babies and are not recommended for crying or spit-up alone. They have side effects, including a higher risk of infections. Doctors reserve them for babies with confirmed GERD complications, such as esophagitis.

Frequently asked questions

Is it normal for my baby to spit up after every feed?

Yes, if your baby is gaining weight, has enough wet diapers and seems comfortable. About half of young babies spit up daily, and some do after nearly every feed. It peaks around 4 months and usually stops by 12 to 18 months as the valve matures and babies sit up.

What are the symptoms of a baby spit up disorder?

Signs that spit-up is more than normal reflux include poor weight gain, refusing feeds, arching and screaming during feeds, chronic cough or wheezing, blood in the spit-up, projectile vomiting, or green vomit. These need assessment for GERD, allergy, pyloric stenosis or a blockage.

When should I worry about my baby spitting up?

Call your doctor if spit-up becomes forceful or projectile, is green, yellow or bloody, starts after 6 months, comes with poor weight gain, fever, lethargy, fewer wet diapers, breathing problems, or blood in the stool. Green vomit needs emergency care.

How do I know if my baby has reflux or a milk allergy?

Both cause spitting up and fussiness. Cow's milk protein allergy is more likely if your baby also has eczema, diarrhea, mucus or blood in the stool, or poor growth, especially with a family history of allergy. A doctor may suggest a 2 to 4 week trial without cow's milk protein.

Should I change formula if my baby spits up a lot?

Not usually. Switching between ordinary formulas rarely helps. If your baby is growing well, smaller, more frequent feeds and burping are better first steps. A thickened formula or, with suspected allergy, a hypoallergenic formula should be chosen with your pediatrician.