Sunday, July 4, 2010

Laundry Problem or a Health Problem?

There is nothing that disturbs new parents more than their infant spitting up. If I were to make a top ten list of things about infants that provoke anxiety, spitting-up would be firmly ranked number one. Nothing else is close. Whether it is the breast milk, formula, or the infant, something is definitely wrong from the parent's perspective. When a baby spits up in a movie or on TV it is funny, but when it is your baby, it is no laughing matter!

At some point in time, spitting up went from a normal part of being a baby to being an abnormality that requires fixing. I am not sure how this happened, but I suspect it is related to the development of medications for reflux. There are medicines that decrease a baby's spitting-up. So when a parent expresses concern about spitting-up, pediatricians reach for medications to "fix" the problem. As more and more infants are being treated for reflux, we have shifted spitting up from a normal part of being a baby to an abnormality that requires drug therapy.

Why do babies spit-up?

There is a muscle (Lower Esophageal Sphincter or LES) at the top of the stomach that is responsible for closing and preventing stomach contents from coming back up. In babies, the LES is not very strong. Although parents always identify the formula or breast milk as the problem, the root of the issue is this muscle. It does not matter what liquid you put down into the baby's stomach, if the LES does not close down tightly, food is coming back up. Despite the fact that only one type of formula (one with added rice starch) has been shown to decrease spitting up, parents jump on the formula carousel. They switch from one formula to the next trying to fix the infant's spitting up. To their amazement the infant continues to spit up. That is because it is a stomach issue not a formula issue.  Combine a weak LES with a liquid diet and the fact that infants spend the majority of their life laying down, babies are born to reflux.

"Does my baby have acid-reflux?"

Reflux implies that the food went the wrong way and the stomach definitely has acid in it. So, yes, if your baby spits up, your baby does have acid reflux. The more important question is: "Does my baby have acid reflux disease?" Disease implies that the acid reflux is causing a problem. The vast majority of infants do not have any problems associated with their reflux (other than frequent clothes changes), so they do not have acid reflux disease.

When should parents worry about spitting up?
  • Poor weight gain. The pediatrician will determine this by looking at the infant's growth chart.
  • Projectile vomiting. This is a forceful vomiting that will shoot several feet. This may require evaluation to ensure there is not a blockage where the stomach empties into the small intestine.
  • Recurrent breathing problems. This most commonly presents as recurrent episodes of wheezing (a noise heard with a stethoscope within the lungs).
  • Excessively fussy infant. It is often hard to tell if an infant is fussy related to reflux or due to other causes, such as colic. But if an infant is miserable and spits up a lot, then reflux may be causing some pain.
These problems are rare. Most infants who spit up are completely healthy and happy, and, therefore, a laundry problem exists but not a health problem. Spitting up is a normal part of being a baby. Accept it. Embrace it. Laugh at it. But you don't have to fix it.

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