GERD (Gastroesophageal Reflux Disease)
Spitting up

All babies spit up, but few needtreatment. 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 have poorly developed lower esophageal sphincters and therefore all have gastroesophageal reflux. As children age this usually resolves.

Normal spitting is non-projectile vomiting of white to yellowish often curdled milk in a happy child who continues to grow well.

Projectile vomiting sprays out with force and can be a sign of a more severe problem. Normal spitting up may come out after every feeding, but typically gets all over the child and parents.

Parents often report their child “spits up everything he eats”. If the child continues to grow well I am not concerned about the reported volume of spit up. In more than ten years of 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/spitting 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 spit up. As long as the acid travels up the esophagus it can cause the pain/fussiness of GERD. Symptoms include general fussiness, spitting up, increased fussiness when lying flat, and arching the back.

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 consider this as a conclusive test for GERD, but it is not. It is possible that a child with severe GERD may not show any episodes during the short study time. I do not recommend Upper GIs for routine GERD as it should not change the child’s treatment.

Treatment of GERD in infants

Universal GERD recommendations:

1.) holding your infant upright for 30 minutes after feeding
2.) frequent burping during feeds

Severe cases of GERD may require:

1.) Adding rice cereal to your 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 are fussy and seem to have reflux, I will often prescribe Zantac. Zantac and other similar medications decreases the amount of acid produced in the stomach. Less acid should mean less pain and fussiness. These acid preventing medications do not reduce the amount a child spits up, but they can make them happier.

By: Dr Gregory Gordon, Pediatrician in Orlando