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Infant GERD/Spitting up
(Gastroesophageal Reflux Disease

As a pediatric intern, my wife and I proudly took our first child to the Department of Pediatrics holiday party. After parking, my wife nursed our daughter so she would not be hungry during the event. Not too many young doctors are brave (or stupid) enough to have a child during their internship. Medical interns are known to work a ridiculous numbers of hours. Many of my memories of that year clouded by fatigue. However, I vividly remember watching my daughter’s spit up soak the suit pants of a prominent pediatric cardiologist at that holiday party.

All babies spit up, but few need medical treatment. It is important to differentiate “normal spitting up” from GERD (gastroesophageal reflux disease). Normal spitting is non-projectile vomiting of white to yellowish often curdled milk in a happy child who continues to grow well. This spit up often looks like a large amount and may soak the baby and their parent. Projectile vomiting, on the other hand, sprays out with force and can be a sign of a more severe problem.

GERD is the extreme form of spitting up. Spitting up becomes a medical problem when is affects a individual’s growth or causes pain.

Parents often report their child “spits up everything he eats”. While, it may look like this to the concerned parent, most babies only spit up a fraction of their milk. Try pouring a few ounces of milk on your floor or a burp cloth. You will quickly see that the amount of “spit up” is not the full feeding. If the child continues to grow well, I am not concerned about the reported volume of spit up. In my pediatric practice, I have yet to see a child who spit up so much they did not gain weight.

The more common treatable concern with GERD is fussiness. When acid from the stomach comes up into a child’s esophagus, it can cause inflammation and pain. It is important to note that not all patients with GERD visibly spit up. As long as the acid travels up the esophagus it can cause the pain and fussiness of GERD. Symptoms include general fussiness, spitting up, increased fussiness when lying flat, and arching the back.

Why do so many babies spit up?

When adults or older children eat, a muscle at the top of the stomach called the lower esophageal sphincter tightens and prohibits the stomach contents from going into the esophagus. Babies universally have poorly developed lower esophageal sphincters and therefore all have some degree of gastroesophageal reflux. Fortunately, as children age, this usually naturally resolves.

To evaluate for GERD many physicians will order an “Upper GI”. This is a radiology study done after a child drinks barium then serial x-rays are taken. The test lasts only 5 to 10 minutes. Some physicians wrongly consider this the diagnostic test for GERD. It is possible that a child with severe GERD may not show any episodes during the short study time. In my opinion, upper GIs are overused and not needed to diagnose most cases of GERD. The diagnosis is made on history, physical exam and response to treatment.

Treatment of GERD in infants

Universal GERD recommendations:
1.) Holding the infant upright for 30 minutes after feeding.
2.) Frequent burping during feeds
3.) Elevating the head of their bed, so that they sleep at a 30 degree angle.

Severe cases of GERD may require:

1.) Adding rice cereal to the child’s milk. This obviously requires more effort if the child is breast feeding. The idea is increased viscosity can keep the milk in the stomach. Medical research shows to make a significant difference you need to add at least one tablespoon of rice per ounce of milk. This amount of rice is impractical, as it is difficult if not impossible to pass this through a nipple. When I do recommend adding rice cereal, I start at one teaspoon per ounce of milk. Even with a third less rice cereal, parents often have to widen the nipple.

2.) Zantac or other acid preventing medication. When children with GERD are fussy, I often prescribe Zantac. Zantac and other similar medications decrease the amount of acid produced in the stomach. For patients with reflux, less acid should mean less pain and fussiness. These acid preventing medications do not reduce the amount a child spits up, but they should reduce at GERD patient’s pain.
In pediatrics, the vast majority of cases of GERD will get better with time. As children grow, their diet becomes less liquid, they learn to walk upright and their stomach musculature (lower esophageal sphincter) matures. These factors lead to GERD symptoms naturally resolving between 6 to 18 months of age.


Updated January 2012 by
Dr. Gordon, Orlando Pediatrician






gregorygordonmd.com is intended to help parents understand the needs and behaviors of children. The information presented in the site is the opinion of Gregory Gordon, M.D.and does not reflect the opinion of his partners. This website is owned exclusively by Doctors insights LLC. The advice in this site does not apply to all children. Always consult your healthcare provider for your individual needs.

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