Baby

BABY SPIT-UP: WHAT'S NORMAL, WHAT'S NOT

By Graciela Wetzler, M.D.

As a pediatric gastroenterologist, the majority of calls I receive are from worried parents whose baby is vomiting. The baby may regurgitate once a day, or after every feeding. In fact, 40 percent of healthy infants regurgitate more than once a day. Usually, he or she is content and is gaining weight -- we call them "happy spitters" -- but the parents are nervous wrecks. They complain that their clothing is stained, their carpets smell, and they're worried that something is seriously wrong with the baby's digestive system. Although in rare instances vomiting may be a sign of a real problem, in most cases it is a benign and transient symptom.

To understand the difference, a short lesson in anatomy:

After a baby swallows food (breast milk, formula or solid food), the food travels through the esophagus into the stomach and then to the small intestine. There is a physiologic valve, called the lower esophageal sphincter, which prevents food from coming back into the esophagus from the stomach. For many babies, this valve relaxes at the wrong time, causing regurgitation. Some babies, especially premature ones, have delayed gastric emptying (I call this "lazy stomach"), which aggravates the problem.

When the regurgitation problem is severe, it's called Gastroesophageal Reflux Disease (GERD). The disease is associated with poor weight gain (due to lack of caloric intake), excessive crying, choking and even respiratory symptoms (such as wheezing, coughing, hoarseness, or pneumonia). Like an adult who has heartburn, your infant may cry due to excess acid in his esophagus. There may also be arching, hiccups, funny faces (such as tongue extrusion) and feeding difficulties (such as pushing the nipple away). Gagging or choking can be dangerous in young babies since they may stop breathing and turn blue. What makes GERD a complex disease is that some babies may have frequent vomiting without any of the associated symptoms, and others may have the associated symptoms without any vomiting. When vomiting is absent, but there is excessive crying due to acid production, GERD is often misdiagnosed as colic.

For the vast majority of babies -- the happy spitters -- the regurgitation symptom peaks by four months of age and usually resolves by the first birthday. As long as your baby appears healthy and is gaining weight, you can be reassured that she will outgrow the problem.

In the meantime, here are a few tips to help an infant who vomits:

• Avoid overfeeding Smaller and more frequent feedings will empty the stomach faster.
  
  
• Minimize intake of air during feeding If the bottle is too low, the baby can swallow air, causing gas and crying.
  
  
• Don't jiggle the baby during and after feeding Too much movement may cause reflux.
  
  
• Sit her in an upright position after feeding Sitting and lying on the back makes reflux worse. Hold the baby in your arms as much as you can.
  
  
• Elevate the crib at a 30-degree angle I suggest using a book under the legs at the head of the crib. Do not use pillows since this can cause suffocation.
  
  
• With your pediatrician's approval, put a baby with severe GERD to sleep on her tummy The American Academy of Pediatrics recommends that babies sleep on their backs in order to avoid SIDS. There is an exemption for babies with severe GERD, since it can improve gastric emptying. Only follow this under doctor's orders.
  
  
• Avoid exposure to tobacco smoke This relaxes the esophageal sphincter.
  
  
• Thicken formula with rice cereal Add one tablespoon of rice cereal for every two ounces of formula and cross-cut the nipple to facilitate the flow of this mixture. Although this may improve reflux, it can cause excessive gas and constipation. Consult your doctor before trying.
  

When these lifestyle measures do not improve the symptom of vomiting, the following medical therapies are available, but should only be tried under doctor's advice:

• Antacids Maalox and Mylanta are over-the-counter drugs, and Zantac liquid is available by prescription.
  
  
• Drugs to improve gastric emptying The most popular drug, Propulsid, is no longer available due to dangerous side effects. But another drug, Reglan, is available, but has side effects that must be considered.
  
  
• Hypoallergenic formula Babies who are allergic to cow's or soy milk may require a different formula. Breast-feeding mothers should go on a milk-free diet with calcium supplement.

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• Baby
• Hygiene
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• Pediatric Nutrition: William J. Klish
• Diet & Nutrition: Linda Hsieh

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