Baby spitting up: is it Normal, Gastroesophageal Reflux or GERD?

Shakespeare wrote about “the infant mewling and puking in the nurse’s arms” when describing the first stage of life.  Spitting was common then and it’s common now—affecting all babies.  But obviously some more than others.  My colleague, Dr. Ben Gold, an expert in the field, lists 3 causes:

  1. A smaller stomach,
  2. A less stretchable stomach, and
  3. The angle the stomach and esophagus make with each other is less than 90 degrees.

I add a 4th:  The strength (or tone) of the valve (the lower esophageal sphincter) between the esophagus and stomach.

The good news: almost all babies grow out of this entirely, with most beginning to improve by 5-8 months of age, when they have outgrown some of the anatomic problems of infancy.  Gravity is working for the babies that are now sitting when they eat, and solids help keep everything down (since it’s much harder to spit up solids than breast milk or liquid formula).  And by 13 months of age, 95% of all infants have completely resolved the condition.  

But until then, they spit.  Often small amounts of digested or undigested stomach contents, right after feedings.  But it can be larger amounts (an entire bottle at times).  Some can come through the nose.  And some can cause them to cough briefly or sputter.  When it’s merely like that, it’s called GASTROESOPHAGEAL REFLUX (meaning, the return of stomach (gastro-) contents into the esophagus).


If the baby is bringing those contents up hours later, sometimes up until the next feeding, the baby may also be having a problem emptying his or her stomach.  If the baby is forcefully vomiting that formula out in a projectile OR if the emesis (the polite, medical term for the material that’s been brought up) contains bile or blood, OR the baby has other problems as well (lethargy, fevers, or an abnormally sized head, for example), then the baby may have a condition other than simple REFLUX.  

And REFLUX isn’t always simple.  That’s when we distinguish it by indicating it’s more significant and calling it GASTROESOPHAGEAL REFLUX DISEASE or GERD.  In What to Feed Your Baby, 6 warning signs that the baby has GERD are listed:

  1. Poor weight gain
  2. Excessive crying or irritability
  3. Head usually tilted to one side
  4. Feeding problems
  5. Respiratory problems: wheezing, apnea, noisy or difficult breathing, recurrent respiratory infections
  6. Symptoms that continue beyond infancy (we’ll discuss that in another post)

Sometimes these symptoms can even occur when the baby isn’t spitting.  He or she may have a feeding problem or pneumonia without anything ever coming out of his or her mouth.  That’s called SILENT REFLUX, and as you might suspect, the GERD becomes much harder to detect.


Often the symptoms are obvious enough that your doctor can make a clinical diagnosis without further testing.  But when the reflux symptoms are more significant, and especially when they are silent and reflux is merely suspected, various studies may be needed to diagnose GERD or determine the extent of the problem.  These can include: endoscopy (using a tube to look inside) and biopsies (taking a bit of tissue for examination) to determine whether there is damage to the esophagus, and/or monitoring the acid coming into the esophagus with what is commonly referred to as a pH probe (sometimes coupled with measuring the mechanical movement of the reflux as well).  If your doctor suspects a cause for the symptoms other than reflux, a wider range of testing might be recommended.


In the same way that testing depends on the extent of the reflux symptoms, so does treatment.  As laid out in the algorithm on this topic in What to Feed Your Baby, the first step is often to manipulate the diet.  Some babies are spitters because they are overfed, getting too much at a meal.  Others simply do better with small, frequent meals or with cereal added to the formula, which thickens the liquid, making it less likely to return.  Thickening has an additional benefit for the lower weight infants.  The extra cereal at 5 calories per teaspoon will quickly add to the babies’ weight.  In the same way, those extra carbs can present an extra burden for the thriving infant.  Fortunately, Enfamil and Similac both make formulas (Enfamil AR and Similac Sensitive for Spit Up) substituting rice starch for lactose, keeping the calories the same as routine cows’ milk-based formula.  

Medications may be needed for more severely affected infants.  These are different acid reducers and blockers that may lessen a baby’s irritability (and the damage done by the reflux).  But they often don’t decrease the actual spitting.  It’s also important to note that these medications can interfere with the effectiveness of the rice starch formulas because they need the baby’s normal stomach acid for the starch to thicken.  And again, it’s important to remember that soon all that spitting and all the extra dry cleaning will come to an end, and you’ll be able to move onto your baby’s next hurdle (instead of his or her hurls).

Dr. Stan Cohen21 March 2016

Dr. Stan Cohen is one of our founders and our CEO as well as the Chairman of our Medical Advisory Board. Dr. Stan is an internationally recognized expert in Read more

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