Spitting up is so common in babies that it is almost a defining feature of infancy. Most babies reflux — bring up small amounts of stomach contents — after feeds. For the majority, it is a laundry problem, not a medical problem. But for some babies, reflux causes genuine pain and feeding difficulties that warrant intervention.
Normal Spitting Up vs Reflux Disease
Normal reflux (GER — gastro-oesophageal reflux) is extremely common, affecting up to 50 percent of babies under 3 months. The lower oesophageal sphincter — the valve between the gullet and the stomach — is immature in young babies and allows stomach contents to flow back up easily. A baby who spits up small amounts after feeds, seems comfortable, and is gaining weight well has normal reflux. No treatment is needed beyond positioning and feeding technique adjustments.
Reflux disease (GORD — gastro-oesophageal reflux disease) is when reflux causes complications. The baby cries during or after feeds, arches their back, seems to be in pain, refuses to feed, is not gaining weight adequately, or wakes frequently with distress. These signs suggest the reflux is causing enough oesophageal irritation to warrant evaluation and possibly treatment.
Silent Reflux
Silent reflux is the most challenging type to identify because there is no visible spitting up. The stomach contents come up and are then swallowed back down — the baby experiences the acid and pain but you do not see it come out. Signs of silent reflux: frequent swallowing or gulping (the swallowing reflex triggered by acid reaching the throat), back-arching during or after feeds, excessive crying particularly after feeds, feeding refusal, persistent hoarse cry or voice, and recurrent ear infections (acid reaching the Eustachian tube).
Management of Normal Reflux
Keep baby upright for 20 to 30 minutes after feeding. Avoid lying flat immediately after feeds. For bottle-fed babies, smaller, more frequent feeds reduce the volume in the stomach at any one time. Burp thoroughly — in India the traditional over-the-shoulder pat after feeding is effective when done with sufficient firmness. Thickening feeds with a small amount of infant cereal reduces the frequency of spitting up (though does not reduce the reflux itself, which is invisible).
When to See a Paediatrician
See your doctor if your baby is losing weight or not gaining adequately, seems to be in pain around feeds, has projectile vomiting (forceful enough to travel across the room), has green or yellow vomit (bile-stained — may indicate an intestinal obstruction, which is a surgical emergency), has blood in vomit, or if normal spitting up is not improving by 6 months. Treatment options including medication are available and effective for GORD when appropriate.