As a childcare provider, you have the opportunity to feed and then burp many infants. Many of them will tend to spit up a little bit when burped, while others will release a geyser of curdled formula all over you.

Generally, spitting up is not a problem, but where does one draw the line between “spitting up” and “vomiting?” And at what point should you be concerned about whether the infant is getting enough nutrition after spitting up copious volumes of formula?

What Causes Spitting Up?

Food enters the esophagus, is pushed downwards by muscular contractions and then enters the stomach. Between the esophagus and the stomach is a muscle called the lower esophageal sphincter (LES). After food enters the stomach, the LES closes like a valve, keeping the food in the stomach. Infants are particularly prone to spitting up because their stomachs are small (about the size of a golf ball), and the LES may not be fully matured yet.

When the infant feeds or swallows too much, air can push the food past this valve and then it comes back up. Spitting up is the regurgitation of food, milk and saliva and it typically is not forceful. Sometimes it appears that the infant is about to smile but instead fluid comes out of their mouth.

Usually, the infants spit up shortly after feeding or burping and the fluid may look like formula or breast milk or have a curdled texture to it. The amount of fluid that the infant spits up may appear to be significant, usually is  only a small amount of what was originally ingested.

More than half of all babies experience spitting up during the first three months after birth; some infants spit up on a regular basis. Spitting up tends to peak at around four months, and most babies stop spitting up by the time they have reached the age of one year (or 12 months).

As the infant grows older, the valve develops and the food is less likely to pass this valve and come back up.  Also, as the child grows older and begins solid foods, there can be less spitting up.

What is the Difference Between Spitting up and Vomiting?

Spitting up is the relatively easy flow of the contents of the stomach flowing out of the mouth, generally accompanied with a burp. Typically, spitting up does not cause discomfort and many babies do not even appear to notice they have spit up.

Vomiting occurs when the baby’s abdominal muscles and the diaphragm suddenly contract when the vomiting center in the brain is stimulated. This center can be stimulated by any of the following:

• When the nerves to the gastrointestinal tract are stimulated by a blockage or an infection
• Reaction to drugs or certain medications
• Stimulation from certain smells, sights, or other psychological input
• Stimulation of the inner ear that can cause motion sickness

Rarely, vomiting may be caused by more serious disorders. For example, an enlargement of the muscle between the stomach and intestine (called “hypertrophic pyloric stenosis”) makes the passage of food from the stomach to the intestine difficult. The symptoms of hypertrophic pyloric stenosis usually appear between the second or third week of life to two months of age.  This condition is serious and must be promptly treated. The vomit may be forceful and shoot out of the mouth.

If the baby appears to be vomiting instead of spitting up, the baby should be immediately examined by a pediatrician. The infant should also be examined if there is any other problem that interferes with the baby keeping his or her food down, such as persistent diarrhea, fever, abnormal fussiness, or breathing problems.

Generally, spitting up is not a serious medical issue. However, be alert to signs of possible dehydration, is a more serious problem:

• Fewer than the usual number of wet diapers
• Soft spot on the baby’s head appears depressed
• Diminished tears when the baby cries
• Baby appears sluggish or persistently tired

A pediatrician should be consulted immediately if these symptoms occur. Medical conditions can become very serious very fast in babies, especially infants less than 6 months of age. Always consult a pediatrician if you suspect illness or any medical problem.

How Can Childcare Providers Prevent Spitting Up?

Spitting up cannot always be prevented, but certain things can be done to minimize the problem:

• Feed smaller amounts of formula more often
• Wait at least 2½ hours between feedings; it takes about that long for the stomach to empty
• Avoid making the diaper too tight because it presses on the infant’s abdomen
• Feed the baby in a more upright position and keep the baby quiet and in an upright position for 30-to-60 minutes after feeding. This allows gravity to let the food move into the intestines without coming back up.
• Decrease the amount of time the baby uses the pacifier. The infant can swallow air while sucking on the pacifier, which can distend the baby’s stomach.
• Make sure the hole in the bottle’s nipple is the right size. If it is too large, the milk will flow too fast. If the hole is too small, the baby gets out of breath and can swallow air. The formula should drip out of the bottle at the rate of 1 drop per second when the bottle is held upside down.
• Allow feeding at a slow enough rate to permit the stomach contents to enter the intestine—no gulping of the liquids.
• Burp the baby at least two or three times during each feeding or after every 2 ounces of formula or breast milk to prevent the build up of air in the stomach.

Spitting up is very common in infants. Knowing what to do and when to be concerned can make feeding the infant more enjoyable for both the childcare provider and the infant.

Joe Knight
Physician Assistant and Medical Writer
Chowchilla, California

Resources

American Academy of Pediatrics, www.healthychildren.org

Emedicine, www.emedicinehealth.comspitting_up_in_infants/article_em.htm

Mayo Clinic, www.mayoclinic.com/health/healthy-baby/PR00044

Medline, www.nlm.nih.gov/medlineplus/ency/article/001920.htm