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If you are a new parent, comparing your situation to that of other new parents is rarely helpful.
But sometimes there is some comfort in knowing that you are not alone.
Reminding yourself that issues you are dealing with are fairly common, can be somewhat of a relief.
And if your baby has just thrown up all over the place, this one is for you.
Let’s start with some empathy from Nurse Judy:
All babies spit up. It is just a fact of life. Of course some of them do it more than others.
My oldest daughter Lauren rarely spit up. I simply didn’t need to pay much attention to the occasional ‘urp’
But as you will learn if you have multiple children, kids do things differently.
My younger daughter gave me a clear understanding of what so many of my patients were fretting about. Alana was a prodigious spitter. It was shocking to me how much this baby could regurgitate! I marveled that any of the milk was actually staying in, but fortunately she grew in leaps and bounds. She was enormous and never dropped her growth percentiles. Alana was the example of a perfectly happy spitter.
I wasn’t quite as blissful. I often didn’t bother changing my shirt unless there were 15 splots of spit up all over it; it simply wasn’t worth it.
My husband Sandy, the clean freak in our family, would follow after her with a spray bottle of Resolve carpet cleaner and a scrub brush, so that she didn’t completely ruin the carpets with the constant puking. (No, he isn’t for rent)
With large babies like Alana, sometimes the spit up is simply the overflow. I know that it is very hard to estimate how much milk your baby is actually spitting out. When I was working at Noe Valley Pediatrics, parents would call me all the time reporting that the baby seemed to spit up the entire meal and yet, there they were, gaining weight just fine. In most cases, the spit ups are not nearly as much volume as you think they are.
In Alana’s case, she ignored the rules, as she most often did, and didn’t slow down with her spitting up until she was seven months old. Most kids will slow it down long before that.
It’s important to distinguish between “reflux” (normal) and GERD (gastro-esophageal reflux disease).
Simple reflux describes what happens with almost all babies: they might be described as “happy spitters.”
This common spitting up resolves with ‘tincture of time’; all babies grow out of it, unlike the disease.
Dr. Ted reminds his patients there’s a light at the end of the tunnel:
Spit up often peaks around 3-4 months of age before it starts to spontaneously show signs of improvement in practically all children. So if things seem like they’re getting worse before they get better… you’re not imagining it. That’s a very normal part of the timeline. And no matter which interventions you try, whichever one you do at 3-4 months will seem like the ultimate cure.
On the other hand, GERD is actually a disease and as such shouldn’t be ignored. It is defined by reflux that seems to cause problems - poor weight gain, excessive fussiness with feeds, arching the back, coughing or sleep disruption linked to spit-ups. The spit-ups usually appear uncomfortable.
Here are some things it is helpful to know about spitting up.
When babies spit up it is not unusual for it to also come out of the nose. This can be scary. If they seem to be having a moment of difficulty when this happens, having a Nose Frida or aspirator handy will help you clear the nasal passages. I remind new parents to always know where it is kept so that you can easily grab it at the moment’s notice.
Once in a while you might note some blood in the spit up. To no ones surprise this tends to freak many parents out, but take a deep breath. Most of the time this is simply a symptom of mom’s sore nipples. There is a good chance that if the nipples are cracked at all, the baby might get a little blood when they are sucking. If it is persistent, there is a way for a lab to check the blood to see if it is from the baby or the mom.
As an aside, if your little baby vampire swallowed some blood during nursing it is also possible that you may see some of it show up in the poop. It will no longer look like fresh blood by the time it makes its way through the system but would more likely look very dark and tarry. If the baby seems perfectly fine, it is very unlikely that they have any type of active bleeding going on.
While most spitting up is fairly benign, projectile vomiting is something that warrants attention. There is a fairly uncommon condition called pyloric stenosis that usually shows up between 2-6 weeks of age. For some reason it is more common in little boys. There is no need to fret about the occasional more forceful spit up, but with pyloric stenosis it might remind you of the movie the exorcist. The spit up literally flies out of your baby and this happens multiple times a day and can land about 3 feet away from the body. Of course you never want to have anything wrong with your baby, but on the scale of things, this condition is very treatable with a simple surgery when caught early (so don’t ignore it). If untreated, it can lead to electrolyte issues and dehydration.
If it feels like your baby is getting thinner, regardless of how fussy they are, it is never the wrong answer to get a weight check! If they’re dropping percentiles they may need an intervention.
Here are things to try if your baby spits up a lot
These are appropriate for ALL spitters. They are also often the first step in managing a GERD diagnosis.
Feeding Strategy Interventions:
Smaller more frequent feedings. This might look like doing multiple “snacky” small feeds during the day, especially in the latter half when the kids are generally more fussy. This might make it feel like you’re constantly feeding your baby, but it’s worth it. Better to spend your time feeding, than cleaning up vomit, or soothing a fussy baby.
If you are bottle feeding, try something called “paced feeding.” This slows the flow of milk to mimic breastfeeding:
You hold the baby more upright (not flat)
Keep the bottle horizontal (not tipped straight down)
Let the baby actively suck to get milk, rather than gravity doing the work
Pause every ~20–30 seconds or every 1–1.5 oz to give breaks and burp
Experiment with different nipples. You want the flow that causes the least air to be swallowed and delivers milk at a slow enough rate that doesn’t promote too much spit-up. There are also bottles out there that tout ‘less air’. There might be some trial and error figuring out what works best for your baby.
Gently warming the milk in the bottle can impact the amount of spit-up. Dr. Ted recognized that his baby Ori was spitting up much more if the milk was cool. We don’t fully understand why this works, but if you notice a difference with your baby it is worth a try.
Gravity helps! After the feed, keep your baby upright as much as possible. The recommendation calls for at least 15-20 minutes of upright time after a feed. That sounds reasonable enough until you actually try to be a rule follower. We recognize that in reality, that 20 minutes is a luxury that you just may not have and you’re lucky if you can get 10 minutes. Do the best you can and try for at least 5 minutes.
There are some wedge pillows available that some parents find helpful. These are not safe to be used for sleep, but are fine for supervised awake time. Wedge pillows can keep babies in an up-angled position to help the milk to flow down.
Some babies are very burp dependent. You will notice that if you aren’t patient enough to get a good burp, part of that meal is going to come back up. Other babies never seem to burp and have no issues. Nurse Judy’s favorite method is to move them from a flat position on your lap and flip them up and over your shoulder. Dr. Ted is a burp evangelist and has a library of at least 10 different moves to ensure an effective burp. Sometimes getting that bubble out includes some creative calisthenics.
Pressure on the belly might make some kids spit up. That might come from a tight diaper (imagine trying to eat a Thanksgiving dinner while wearing spanx), or from tummy time on a hard floor right after a feed.
Dietary Interventions
Breast feeding moms should see if there are any dietary factors that impact the spitting. This doesn’t mean you need to go on a full elimination diet right away (please don’t make your life harder than it already is). But if you start to notice a pattern, like more spit up, fussiness, or gassiness after certain foods, it’s reasonable to experiment with cutting one thing out at a time for a week or two. The most common culprit is dairy, but it’s not the only one. If you do try eliminating something, give it a little time, these changes aren’t immediate. And if you don’t see a difference, don’t be afraid to add it back in. The goal here is not perfection, it’s just seeing if there’s an obvious trigger that’s easy to fix.
Probiotics may be useful. This is one of those “might help, probably won’t hurt” interventions. Some babies seem a little less gassy and a little more comfortable on them. Others may show absolutely no change. If you decide to try one, give it a week or two and see if you notice a difference. If not, no need to keep going. There’s no prize for the longest probiotic streak. When the issue is excessive spitting, we tend to reach for ones that contain Lactobacillus reuteri, which has a bit of data behind it in infants. But again, this is not a magic fix, it’s more of a gentle nudge in the right direction for some babies.
Babies getting formula might improve using one of the sensitive formulas. Every formula reacts differently. Dr. Ted has noticed anecdotally that many of his patients do very well starting off with the Kirkland brand formula, but if your baby has reflux disease, most brands have a separate “sensitive” version. There are some very good specialty formulas to investigate as well, but they tend to be fairly pricey.
Reminder: If you’re going down the formula rabbit hole, try not to change five things at once (we know…easier said than done when you’re tired and your baby just spit up on your last clean shirt). Pick one formula, give it a solid 5–7 days if you can, and see how your baby does. These changes take a little time, and switching too quickly can make it hard to know what’s actually helping. If things aren’t improving, it’s reasonable to step up gradually, from a standard formula to a “sensitive” one, and then to a more specialized option if needed. Most babies do not need the very expensive formulas, but there are situations where they can make a big difference. And just to say it out loud: if your baby is gaining weight and generally content, a lot of spit up alone doesn’t mean you need to keep switching formulas in search of perfection. Sometimes the best formula is the one your baby tolerates reasonably well… and that you can actually find at the store without stress.
Medical Interventions
If you have done 2 to 4 weeks of the above interventions and have seen no significant improvement it is time to make a plan with your doctor. Start the discussion and evaluation with a weight check, so an office visit is usually needed.
Your pediatrician may suggest thickening the feeds. To do this, start small with a teaspoon of oatmeal or rice cereal to 2-4 ounces of formula. This can help the milk stay down in the stomach a bit better. Keep in mind that a faster flow nipple might be required for the thicker milk. If you want to keep it simple, there are some formulas that are thickened with rice starch, such as Enfamil AR.
Medications are used as a last resort for babies that have a true diagnosis of GERD (reflux disease), not the happy spitters. If you’ve tried everything on the list above, and you’ve committed a good 4+ weeks to the behavioral and dietary interventions without good effect, medications can be considered if it is suspected that stomach acid is the cause of the reflux symptoms. These are the babies who are consistently arching, refusing feeding and or struggling to gain weight.
Medications are usually tried for a short window ( about 4-8 weeks) with the goal of using the lowest dose for the shortest amount of time possible.
If it’s not clearly helping, it is time to stop and rethink the plan. This might be time for a referral to a specialist.
Reminder:These medications are helpful in the right situation, but they’re not a magic fix—and most babies don’t need them.
Alternative approaches to consider
Traditional Chinese Medicine (TCM)
Nurse Judy asked her ‘go-to’ acupuncturist to weigh in on this topic.
Traditional Chinese Medicine (TCM) views spitting up and reflux as an imbalance in a baby’s immature and developing digestive system. TCM approaches are extremely gentle and safe, including some possible changes to feeding practices (that of a nursing parent and/or the baby), massage, warming the baby’s digestive system, activating specific acupuncture points (needles NOT necessary), and sometimes an herbal remedy for the nursing parent and/or the baby. Dr. Den specializes in pediatrics, and regularly works with babies experiencing a lot of spit up or reflux, and the relief can be tremendous, for both the baby and their concerned parents. Reach out to Dr. Den with any questions, or schedule an appointment directly through her website: The Acupuncture Den.
Chiropractic
While clinical data proving that this works is limited, anecdotally, Nurse Judy’s chiropractor Sandra Roddy Adams, says that she has treated many babies who appear much more relaxed following a gentle adjustment. She speculated that the all important vagus nerve is part of that equation, although there have been no studies to definitively prove this.
Random Extra thoughts
Skin folds
Kids who do a lot of drooling and spitting up can be prone to skin irritations in the skin folds of the neck and the area behind their ears. Make sure you do a daily skin check. Being proactive will work in your favor. It is much easier to prevent a nasty skin fold rash than it is to clear it up.
Sleep
Parents often express concern about the baby spitting up and choking if they are on their back. Fortunately, repeated studies are reassuring. Babies’ anatomy actually makes choking more likely when they are lying on their bellies.
So, even if they are frequent spitters, it is still strongly recommended that you place them on their backs when they are sleeping. The data backs that up!
You might have noticed this marvelous new model!
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Introducing Ori Handler!
Mazel Tov to Dr Ted and his husband Chris!
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