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Ask Dr. Sears: When a Fussy Baby Spits Up

Q. My one-month-old has been spitting up frequently and is very fussy beforehand. I have ruled out diaper changes, over-stimulation, and anything else that might be making her overly fussy. She burps very well after breastfeeding, and I keep her upright for at least twenty minutes after she eats. She was prematureborn at 36 weeks. Most of the time her spit-up is not right after she eats, but when she is sleeping. (She will normally fall asleep after eating.) She gasps for air when she spits up when sleeping, and I am afraid she is going to choke on it. What can I do?

A. Your description gives clues that your baby is spitting up because of a condition called gastroesophageal reflux (GER). Normally, when food travels down the esophagus into the stomach a circular band of muscle at the end of the esophagus contracts and acts like a one-way valve to keep food in the stomach where it can be digested and travel down the rest of the intestines. In some babies, this muscle, called the lower esophageal sphincter (LES), is immature, allowing milk and stomach acids to be regurgitated back up into the esophagus, causing baby to spit up. The stomach acid can also irritate the sensitive lining of the esophagus, causing a pain like baby heartburn, which could account for your baby being fussy. The fact that it happens more during sleep is typical of reflux, since the upright position allows gravity to help keep the food down. Around one-third of all babies have some degree of reflux, and GER is more common in premature babies. While spitting up in most babies is nothing more than a temporary laundry problem, in your baby, and other babies with GER, it is a painful, yet treatable, problem. Here's how to lessen your baby's reflux:

Feed baby more frequently 

Dr. Bill's reflux rule is: "Feed baby twice as often and half as much." Small, frequent feedings are the key to more comfortable feedings in a baby with reflux. By feeding baby more frequently, the milk will empty faster from the stomach, leaving less milk in the tummy to be spit-up.

Continue breastfeeding 

Breastfeeding and breastmilk is a natural medicine for babies with GER. Breastmilk empties from the stomach much faster than does infant formula. Breastmilk is also a natural laxative. Constipation aggravates reflux by increasing the intra-abdominal pressure during straining, causing babies to spit up more. Also, babies with reflux tend to have a higher incidence of allergies to infant formula. If a situation occurs in which you have to give your baby some infant formula, use a predigested formula (e.g. Nutramigen or Alimentum), which empties from the stomach faster than standard infant formulas.

Keep baby upright 

Gravity is a friend to a baby with reflux. As you are now doing, keep your baby upright for at least twenty minutes after a feeding. This helps the milk empty from the stomach faster.

Elevate baby's bed 

Since reflux seems to be most painful during sleep or when lying in the horizontal position, if baby is sleeping in a crib, elevate the head of the crib around thirty degrees or try a reflux wedge (available at infant product stores) that will help baby sleep more upright.

Encourage comfort sucking 

Saliva is a natural lubricant to soothe an irritated esophagus. It also contains natural substances that help the irritated lining of the esophagus heal. Between feedings, encourage baby to suck on your finger or on a pacifier. Most babies with reflux instinctively suck more often, since they make the connection between increased saliva flow and a feel-better tummy.

Keep a diary 

Make a list of the most concerning symptoms, such as: frequent spit-up, painful nightwaking, colicky abdominal pain, fussy behavior shortly after eating, or throaty and choking sounds. After you've made the above interventions, chart whether these signs and symptoms are getting better, worse, or staying the same. Take the chart into your baby's doctor. While most babies with mild reflux can be handled with the above home remedies, some babies will temporarily need a medicine to lessen the secretion of stomach acids. Your chart will help your doctor make the decision if and what medicine to prescribe.

Get support for reflux 

A helpful online resource is Pediatric and Adolescent Gastroesophageal Reflux Organization. This organization was founded and is maintained by parents of babies and children with reflux.

GER is one of the most commonly overlooked causes of so-called infant "colic." It usually begins to subside in most infants between six and nine months when baby's digestion becomes more mature and baby spends more time upright.