Reflux and starting solids: spit-up, GER and GERD

Spitting up is normal

Regurgitation and spitting up are normal in babies under 1, according to the NIDDK (part of the US National Institutes of Health). About 70 to 85 percent of babies bring up milk every day by 2 months old, and most no longer have symptoms by 12 to 14 months.

The AAP says reflux usually starts at about 2 to 3 weeks, peaks at 4 to 5 months, and goes away by 9 to 12 months for most babies born at full term. Many are “happy spitters”: they don’t seem bothered, and may even feel better after a good spit-up. The NHS says a baby with reflux doesn’t usually need to see a doctor, as long as they’re happy, healthy and gaining weight.

Why it happens. The ring of muscle at the top of a baby’s stomach isn’t fully developed yet, so milk comes back up easily (NHS, AAP). Babies also spend a lot of time lying down, and their meals are liquid and large for their size (NIDDK). The muscle gets stronger as your baby grows.

GER or GERD?

GER (gastroesophageal reflux) is the normal spit-up described above. GERD (gastroesophageal reflux disease) is when reflux causes repeated, bothersome symptoms or leads to complications (NIDDK). It’s much less common: the AAP’s symptom guide puts it at less than 1% of babies.

Signs that may point to GERD include (AAP, NIDDK):

• refusing feeds, or losing interest in eating
• crying or arching their back during feeds, as if in pain
• poor weight gain, or fewer wet and dirty diapers
• coughing, wheezing, or choking on milk often
• spit-up that becomes more frequent or more forceful

The NIDDK notes that many other conditions can cause similar symptoms, so doctors may check for other causes first. Cow’s milk allergy can look very like reflux (NHS, AAP): see cow’s milk allergy. Some babies have reflux without bringing milk up, which the NHS calls silent reflux.

Do solids help with reflux?

They often do, gently and over time. The AAP says normal development, including better head control, sitting up and starting solid food, helps improve reflux. The NIDDK says that as babies spend more time upright, eat more solid food and grow, they usually have less reflux. The AAP’s symptom guide adds that many babies are better by about 7 months, once they can sit well.

That doesn’t mean starting solids early. The advice for babies with reflux is the same as for every baby: start at around 6 months, when your baby shows the readiness signs together, and never before 4 months. See is my baby ready for solids? If you’re thinking of starting earlier because of reflux, talk to your pediatrician or health visitor first.

When you do start:

• Sit your baby upright in a high chair for meals, so they can swallow properly (NHS).
• Go at their pace. Offer small amounts and stop when they show you they’re full (NHS). The AAP says overfeeding makes spitting up worse.
• Keep it calm afterward. The AAP suggests limiting active play for about 20 to 30 minutes after meals, and putting off tummy time for a while after eating.

For toddlers, the AAP says diet can play more of a role. Large meals, fried and fatty foods, very acidic or spicy food, and fizzy or caffeinated drinks can make reflux worse. If one food seems to cause symptoms, the AAP suggests leaving it out for a week or two, then trying it again. If symptoms come back, avoid it until your pediatrician says to add it back.

Thickening: only on medical advice

You may hear that adding cereal to a bottle helps reflux. Don’t do this on your own.

• The AAP says not to put baby cereal in a bottle, because your baby could choke, and it can lead to eating too much. A pediatrician may sometimes recommend it for reflux: check with your doctor first.
• If your pediatrician does recommend thickening, the AAP suggests a very small amount of infant oatmeal rather than rice cereal, because of arsenic in rice. See rice and arsenic.
• The NHS says not to put anything other than breast milk or formula in a bottle. A GP or specialist may first check for cow’s milk allergy, then may suggest a thickening powder or a pre-thickened formula for formula-fed babies.
• One older AAP symptom-checker page still suggests mixing rice cereal into formula at home. Other AAP pages say never to add cereal to a bottle unless your pediatrician advises it, and to use oatmeal rather than rice. We follow the newer advice: check with your doctor first.

Medicines are only for babies with GERD whose symptoms don’t improve with other changes. The NIDDK says not to give babies reflux medicines unless a doctor tells you to, and the AAP says acid-blocking medicines don’t help normal spit-up and can have side effects.

Everyday things that help

These come from the NHS, the AAP and the NIDDK:

• Hold your baby upright during feeds, and for about 20 to 30 minutes afterward if you can. Stay with them during this time.
• Burp your baby during feeds, not just at the end.
• Try smaller feeds more often, as long as your baby still gets enough to stay hydrated and grow (AAP). Feeding before your baby gets very hungry can help.
• Ask your health visitor or a feeding specialist to check breastfeeding position or bottle-feeding technique (NHS).
• Keep your baby away from cigarette smoke (NIDDK).
• Always put your baby to sleep flat on their back. The NHS says not to raise the head of the crib or Moses basket.

When to see a doctor

Talk to your pediatrician, GP or health visitor if your baby (NHS, AAP, NIDDK):

• isn’t improving after you’ve tried the steps above
• gets reflux for the first time after 6 months old
• still has reflux after their first birthday
• isn’t gaining weight, or is losing weight
• refuses feeds, or cries and arches during feeds
• coughs, wheezes or chokes on milk often
• spits up more often or more forcefully than before

When to get help quickly

Forceful vomiting that shoots out after every feed can be a sign of a condition called pyloric stenosis, most often between 2 weeks and 2 months old. The AAP says to call your pediatrician right away. The NIDDK also says to call a doctor right away if vomiting or spitting up starts before your baby is 2 weeks old.

Call your pediatrician right away for projectile vomiting, blood in their poop, a swollen or hard belly, or signs of dehydration, such as no wet diaper for 3 hours or more, or a lack of energy (AAP, NIDDK).The NHS says to ask for an urgent GP appointment or call 111 if your baby has projectile vomiting, blood in their poo, a swollen or tender tummy, signs of dehydration, keeps being sick and can’t keep fluids down, won’t stop crying, or refuses to feed.Get urgent medical help, the same day, if your baby has projectile vomiting, blood in their poo, a swollen or hard tummy, or signs of dehydration.

Call 911 or go to the emergency room if your baby:Call 999 or go to A&E if your baby:Call your local emergency number (such as 112 in Europe or 000 in Australia) or go to the emergency department if your baby:

• has green or yellow-green vomit or spit-up (NHS). The AAP names bile (green color) in the spit-up.
• vomits blood, or vomit that looks like coffee grounds (NHS)
• is struggling to breathe, or has blue, gray or blotchy skin, lips or tongue
• is floppy or hard to wake
• hasn’t had a wet diaper or peed in 12 hours (NHS)

Where US and UK advice differs

• Thickening. In the US, a pediatrician may recommend a very small amount of infant oatmeal in formula. The NHS describes a thickening powder or pre-thickened formula, after checking for cow’s milk allergy. Both: only on medical advice.
• Green vomit. The AAP’s symptom guide sends babies with green spit-up to the emergency room straight away, and the NHS food poisoning and vomiting pages say to call 999 or go to A&E for yellow-green or green vomit in children, or for vomiting blood. The NHS reflux page lists green or yellow vomit under an urgent GP appointment or 111. We follow the stricter advice: treat green vomit, or blood in vomit, as an emergency wherever you live.
• Starting solids a little earlier. Both the AAP and NHS recommend starting at around 6 months. One NHS trust leaflet (Kingston and Richmond) says starting solids at 18 weeks, and not before, has helped reflux in some babies. If you’re considering this, talk to your health visitor or doctor first.

For most babies, reflux fades with time. If you’re struggling to cope, tell your health visitor or doctor (Kingston and Richmond NHS).