When is Frequent Spit-Up a Disease?

  • What is Reflux (GER)?

    About half of all babies have GER, spitting up (the most visible behavior) several times a day. GER happens when digested food and stomach acids flow back up into the esophagus. The trapdoor between the esophagus and the stomach (lower esophageal sphincter muscle) is weak. Plus, babies spend lots of time lying down, making it easier for food to come back up. In most cases, reflux doesn’t hurt, and they’re just “happy spitters.”

    What is Gastroesophageal Reflux Disease (GERD)?

    While it’s common for healthy babies to spit up, frequent vomiting associated with weight loss, difficulty feeding and other serious symptoms may be caused by GERD. These complications can include:

    • Recurrent vomiting and poor weight gain
    • Recurrent vomiting and irritability
    • Esophagitis
    • Dysphagia or feeding refusal
    • Apnea or ALTE (apparent life-threatening event)
    • Asthma
    • Recurrent pneumonia
    • Upper airway symptoms
    • Unusual arching or seizure-like movements (Sandifer syndrome)

    Identifying GER or GERD

    Being able to distinguish between GER and GERD is important to implement best practices in managing reflux in all of your clients. Children with GERD may benefit from further testing and treatment.

    For most babies, a history and physical exam when there are no GERD warning signs are enough to reliably identify uncomplicated GER.

    When evaluating GERD, the history and physical exam can help you recognize complications of GERD and exclude other worrisome disorders that present with vomiting.

    No single test can rule GERD in or out. But some tests can help evaluate babies with GERD symptoms. These diagnostic approaches include:

    • Upper GI series
    • Esophageal pH monitoring
    • Esophagogastroduodenoscopy and biopsy
    • Empirical medical therapy

    To learn more about testing methods, see: http://pediatrics.aappublications.org/content/131/5/e1684

    Managing GER with Lifestyle Changes

    For babies who are “happy spitters,” conservative management techniques can help:

    • Normalize feeding volume and frequency
    • Consider thickened formula
    • Consider non-prone (not face down) position during sleep

    Managing GERD with Lifestyle Changes


    Modifying mom’s diet if baby is breastfed.

    A two- to four-week trial of maternal exclusion diet that restricts at least milk and egg is recommended in breastfed infants with GERD symptoms. (A milk protein allergy can cause a clinical presentation that mimics GERD in babies.)


    Keeping baby upright after eating or even placing baby prone may be helpful. Studies using impedance and pH monitoring have confirmed older studies that used pH monitoring to demonstrate significantly less GER in babies in the flat prone position compared with the flat supine position. But when positioning babies with GERD, the risk of sudden infant death syndrome in sleeping infants outweighs the benefits of prone positioning—and baby should be placed in prone position only when observed and awake.

    Treatment with Medications

    Medications are indicated only for clients with GERD. While they can help control symptoms, promote healing, prevent complications and improve health-related quality of life, carefully weigh benefits against potential adverse effects.

    The two major classes of pharmacologic agents for treatment of GERD are acid suppressants and prokinetic agents.

    Learn more about medications to treat GERD at: http://pediatrics.aappublications.org/content/131/5/e1684 .

    * WIC is a registered trademark of the United States Department of Agriculture (USDA) for Women, Infants and Children program. No endorsement of any brand or product by the USDA is implied or intended.