Spit-Up, Vomiting and Reflux: Know What Is Normal and the Warning Signs

You have just finished breastfeeding or the bottle, and your baby brings some of the milk back up onto your shoulder. This scene happens many times a day in many homes. Most of the time it is completely normal. Still, knowing how to tell normal spit-up from vomiting that needs a doctor will put your mind at ease.

What are spit-up and reflux? When stomach contents come back up into the food pipe, it is called gastroesophageal reflux (GER). In babies, this usually shows up as milk coming out of the mouth during or right after a feed. According to the American Academy of Pediatrics (AAP), normal reflux usually starts at 2-3 weeks of age and peaks at around 4-5 months. According to the AAP, spit-up and vomiting are not the same thing: with spit-up, a small amount of milk flows easily out of the mouth, often with a burp, and does not bother the baby. Vomiting is when stomach contents are forced out by strong contractions of the belly muscles, and it usually causes discomfort.

Happy spitters. The AAP calls babies who spit up without being fussy or seeming to be in pain happy spitters. According to the NHS, reflux usually starts before a baby is 8 weeks old and gets better by age 1. The AAP also says that in most full-term babies, symptoms go away by 9-12 months. So most of the time, it is simply a matter of time.

The difference between reflux and reflux disease: According to the AAP, when reflux causes problems or other symptoms in a baby, it is called gastroesophageal reflux disease (GERD). These may point to reflux disease:

• Refusing to feed
• Crying or arching the back like a bow while feeding
• Breathing symptoms such as wheezing or coughing
• Blood in the spit-up, or spit-up becoming more frequent or more forceful
• Not gaining enough weight, or fewer wet diapers

According to the AAP, the first step is usually changes to feeding and positioning. Medicine only comes up if symptoms continue despite these changes, and that decision is made by the doctor.

Tips to reduce spit-up:

• Feed smaller amounts more often (AAP).
• Hold your baby upright while feeding (NHS).
• Burp them not only at the end but also during the feed (AAP, NHS).
• Keep your baby upright for 20-30 minutes after feeding and avoid active play during this time (AAP).
• Ask a midwife, nurse or family doctor for help with breastfeeding or bottle-feeding positions (NHS).

Sleep: on the back, even with reflux. The NHS stresses that babies with reflux should also sleep on their back on a flat surface, not on their side or tummy. The NHS also says the head end of the crib or bed should not be raised. Safe sleep rules apply just the same with reflux.

Pyloric stenosis: projectile vomiting. According to the AAP, in pyloric stenosis the muscle at the stomach outlet thickens and blocks food from passing through. It usually starts between 2 weeks and 4 months of age. The typical sign is forceful, projectile vomiting about 15-30 minutes after every feed. If you notice vomiting like this, call your pediatrician right away.

Green vomit is an emergency. The AAP counts bile (green material) or blood in vomit as an emergency sign. The NHS also recommends getting help right away for green or yellow vomit and vomit with blood in it. In this case, have your baby checked without waiting.

Watch for dehydration. According to the AAP, a dry mouth, no tears when crying, a sunken soft spot (fontanelle) and peeing less are signs of dehydration. In a baby who vomits often, keep a close eye on these signs.

When to see a doctor, when to call your local emergency number? According to the NHS, see your family doctor if:

• Things do not improve despite the tips
• Reflux starts for the first time after 6 months or continues after age 1
• Your baby is losing weight or not gaining enough

Go to the ER or call your local emergency number without waiting if there is:

• Green or yellow vomit, or blood in the vomit
• Projectile vomiting
• Blood in the poop
• A swollen or tender belly
• Not keeping any fluids down, or refusing to feed
• A very high fever, or severe crying that will not stop
• Signs of dehydration or obvious weakness

Dear mom, milk stains on your shoulder are the most common keepsake of this stage. For a happy baby who is gaining weight, spit-up usually just means more laundry. If you have any doubts, do not hesitate to ask your doctor; you know your baby best.