By Dr. Harohalli R. Shashidhar
At least half of all infants spit up in the first six months of life, but the majority of these do not experience problems from reflux. Troublesome or complicated reflux is called gastroesophageal reflux disease or GERD. How do we distinguish uncomplicated baby spit-ups from GERD?
Some infants spit up frequently and will not usually require any medications. These spit-ups at their worst are a nuisance and may make parents anxious often because it appears to be a large volume. Weight gain is rarely affected.
These ‘happy spitters’ may benefit from simple measures that include keeping the baby in an upright posture after feeding and thickening foods with baby rice cereal. These infants do not require any intervention apart from parental reassurance.
Weight gain and growth assessment in infancy is a wonderful tool to assess impact of any disease. This applies to infant reflux. A series of weights on a growth curve are more informative than a single weight recorded at any one point.
Some infant troubles with feeding and fussiness may be related to acid irritation, the equivalent of heartburn in the adult. This will require a medical consultation to properly diagnose, and acid-suppressing medications may help.
However, not all feeding-related fussiness is due to acid reflux. Another common cause is difficult or painful bowel movements. Infants have an exaggerated gastrocolic reflex, the urge to evacuate the bowels immediately after eating. That may lead to crying or discomfort.
Newborns with acid reflux may also exhibit breath-holding spells, where they look pale or blue, as if they are struggling to breathe. Many of these symptoms may also be related to inadequate or poor coordination of sucking, swallowing and breathing related to neurological immaturity, a learning curve especially for premature babies or those with low birth weight. Breath-holding, or apneic spells, require a thorough medical evaluation including observation in the hospital.
Certain indicators require a prompt medical attention. Presence of bile in the vomit, or vomiting leading to dehydration or electrolyte abnormalities, require tests to rule out a bowel obstruction. Blood in the vomit also dictates further tests. Failure to gain weight demands a careful evaluation for other causes of inadequate growth.
Premature or low-birth-weight infants may be more prone to feeding difficulties and aspiration from acid reflux. Infants with neuromuscular conditions that alter muscular tone, such as cerebral palsy, are likely to have a more severe form of acid reflux including esophagitis or aspiration. In these infants, symptoms may also persist beyond 12-18 months. Infants who have undergone surgery on the esophagus or upper airway are also likely to experience more severe reflux.
Infant spit-ups are common and usually do not result in any serious consequences such as weight loss or esophageal inflammation. When growing well and thriving, these infants do not benefit from further tests or medications. Infants who experience feeding difficulty or who refuse to feed – and those who experience aspiration episodes or blue spells – demand prompt attention.
Dr. Harohalli R. Shashidhar is associate professor of pediatrics, University of Kentucky College of Medicine and chief of pediatric gastroenterology and nutrition, Kentucky Children's Hospital