Really, Now, How Much Spitting Is Too Much?

We’ve all seen them—babies that seem to be the perfect little ladies and gentlemen—until someone tries to feed them. Suddenly, what was meant to be in the first stages of digestion is instead on the feeder’s shirt. Yes, it’s a spitty baby, and other than a change of clothes, the first thing on the feeder’s mind might be how to avoid a repeat performance. And if it’s been happening a lot, there might be some questions as to whether it’s normal, or whether there is something wrong.

It’s now been said so often that it’s practically a proverb—spit happens. The reason it occurs so readily in young infants is that the gastrointestinal system—that long tube that starts with the mouth and continues on down to the diaper area—is immature. Most commonly, the specific culprit is the lower part of the esophagus, the food tube that empties into the stomach. Normally, the esophageal muscle, or sphincter, tightens up to avoid food going the wrong way. But it’s a little more relaxed in our youngest feeders, which allows food to go up and out.

Generally, this is a normal phenomenon. But is there a point where this is a problem? (Note that I have not distinguished spitting from vomiting here. Vomiting usually implies a more forceful process where babies are using their muscle to expel what’s in the stomach. That can be more concerning, especially if there is green or blood in the contents. But if not, it can be difficult to differentiate the two.)

When to Worry

While lots of healthy babies spit, there are a few conditions that pediatricians come across with some frequency. Gastroesophageal reflux disease is basically an extreme version of feeding coming up the wrong way. Most babies with this are visually uncomfortable after feeds, and may have other symptoms such as difficulty breathing. Babies with pyloric stenosis have a narrowing at the point where the stomach empties into the small intestine. They may look happy but generally aren’t growing well, especially if the diagnosis is delayed. The provider can sometimes suspect pyloric stenosis based on an exam, but a definitive diagnosis is made by ultrasound.

Occasionally, vomiting can mean disease outside the gastrointestinal system. Sometimes an infection or, more rarely, a genetic disease that affects the body’s chemicals can cause vomiting. In these cases, however, babies usually don’t look well and often feed poorly. Finally, although many parents worry about a spitty child having a formula or even a breast milk allergy (or an allergy to something a breastfeeding Mom is eating), most spitting without other symptoms is not food allergy.

But You Still Haven’t Answered the Question! How Much Is Too Much?

It would be glorious to be able to put a “red flag number” on the amount of spit-up a baby makes. The reality is, there is no number. An infant can spit with every feed and it can still be normal. More importantly, a little can look like a lot. To see what it looks like, spill a tablespoon of milk on a kitchen counter (or you could be even more realistic and use a towel) and see how much it looks like. Or, if you’re like me and get a little overzealous with your morning coffee, you know what happens when the lid to the travel mug isn’t screwed on tight and how prominent a dribble appears!

When in doubt, your baby can be checked by his provider. In addition to being checked for a more serious cause, he can be weighed. Although plants can thrive and grow from photosynthesis, humans have to take in energy by mouth to grow. If the baby is growing, then much of his feeding is staying in.

A Few Thoughts on What to Do (and What Not to Do)

If your little one’s provider has been able to reassure you about her overall health, a lot of the treatment involves watchful waiting. Feeding upright and keeping her upright for 30 minutes after feeding may help. So might frequent burping and, for bottle fed infants, experimenting with different bottles and nipples so she is not spitting from an air bubble. (Breastfeeding is generally pretty efficient, and babies swallow less air.) Watch total intake—some spitting is from overfeeding—and if the total amount is reasonable, consider more frequent small feeds. Avoid active playtime after feeds which can overstimulate the baby and lead to vomiting.

One thing you probably don’t want to do without running it by your infant’s provider is change formulas (or, even worse, discontinue breastfeeding for this problem). It’s not helpful all that often, and you may be stuck with a lot of different brands. If you do find one that helps, your provider will likely OK it; however, if you receive supplemental assistance (say, from the Women Infants and Children program), the program will not approve a special formula for spitting alone. Finally, safety first! It may seem like a good idea to put your spitty baby to sleep on his stomach, but studies have shown that even for this group, “back to sleep” is safer.

Stan Sack
Dr. Stan Sack has 29 years’ experience as a primary care pediatrician in Massachusetts and Florida. A medical writer since 2015, he enjoys blogging on topics that are on parents’ minds but are covered less often in books and on websites. He lives in the Florida Keys with his family and enjoys healthy cooking, fitness activities and singing in his spare time.

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