Q: I have a 3 month old son who spits up his milk, almost after every feed and at times even during the feedings.. Its constant and I was told not to worry because he will outgrow it. It worries me a great deal because I wonder if this may lead to weight loss at some point. I have given up wearing nice clothes because of all the vomiting!
A: It is very common for babies to spit up. Close to 45 % of babies, aged 3-4 months, experience this situation and by one year the incidence drops down to less than 5% of babies.
Other terms used for this condition are: regurgitation, reflux, innocent vomiting, leakage and spilling (The latter term, thought to originate in Australia, has become popular even among some physicians according to a lecture on reflux at the recent Canadian Pediatric Society Annual Meeting in Ottawa)
The problem unfolds when the front door to the stomach leaks. There is a valve in that part of the body, known as the gastro-esophageal sphincter. When this valve is weak or when it is not able to prevent the regurgitation of stomach contents backing up into the esophagus, babies may spit up or spill their milk.
Many babies are still happy when this happens but a few may get very upset and become irritable, arch their backs, refuse to feed and even have more serious issues over time if the problem does not resolve.
It is worrisome when a baby who spits up loses weight, brings up blood, develop anemia, has a tender abdomen, vomits bile, struggle to swallow, chokes to the point of struggling to breathe, or ends up with stomach acid in the lungs (aspiration)
Although it is common in babies, some medical conditions seem to have a higher incidence of spitting up: patients with cystic fibrosis, obesity, a family history of reflux and patients with chronic neurological symptoms (for example Cerebral Palsy) seem to be at an increased risk
It is important to understand that ongoing, forceful vomiting—especially in the first few weeks of life---is probably not due to reflux. Pyloric stenosis must be excluded in these babies. Pyloric stenosis is a situation where the back door of the stomach, the exit point, has an overdeveloped muscle which causes obstruction. This requires surgery and if not fixed in a timely manner, may lead to serious complications. Before Dr Ramstead, a surgeon, found a way to solve this issue, a number of babies died as a result of pyloric stenosis.
If the degree of reflux is severe and if it fails to improve over time one must be alert to other conditions that may be associated with or which can be aggravated by reflux. These are asthma, dental erosions, laryngeal damage, sinus and middle ear infections, halitosis and pneumonia.
The diagnosis of reflux is mainly made via a clinical history. One condition which may be confused with reflux is colic. In fact, some experts have referred to reflux as "the new Colic" Urinary tract infections, allergies and constipation must also be excluded before a physician can be more certain of reflux as the cause of irritability or excessive crying.
Previously, a barium swallow was used more often than now to make a diagnosis. However, an expert -panel of gastroenterologists have argued that this test is not useful. It also is associated with a great amount of additional radiation due to the numerous number of x-ray exposures it requires.
Another objective attempt at picking up reflux is a 24 hour pH probe. It requires the insertion of a device that is left in the area where the low stomach pH (acid reflux) will take place. This can only be done with the help of an expert such as a gastroenterologist and currently in Canada, pediatric gastroenterologists are in short supply; they often have extraordinary long waiting lists
The management of choice is firstly conservative measures such as smaller and more frequent feeds, thickening the milk with rice cereal, elevating the head of the bed, avoiding pressure on the stomach and using formulas which are better tolerated by babies who spit up (this choice is not often supported by evidence and some formula companies stand accused of using marketing approaches more than science.)
If these measures fail one can try an antacid; if that fails a medication known as a histamine receptor antagonist may be tried. Finally a medication such as Losec or Prevacid---known as proton pump inhibitors (PPI's)--- may be used. They reduce the amount of stomach acid.
The use of these PPI's has climbed seven fold between 1999 and 2004. It concerns some experts who argue that these products are over - used in patients who may not even have reflux. Recent data also raised concerns of Vit B12 deficiencies as a result of these medications, a higher risk of pneumonia and some bone disease (in adults) The thinking is that some acid production is needed for optimal health; suppressing stomach acid too much may have side effects.
In the past a logical approach was used: medication that empties the stomach more rapidly thus reducing the chance of spilling. Unfortunately, these medications, known as prokinetics, have failed due to side effects that out weight potential benefits.
If medication fails and especially so in patients with associated neurological issues, a surgical procedure known as the Nissen Fundoplication can be tried (its surgery which involves wrapping part of the stomach around the esophagus) For more information on reflux visit www.kidshealth.com and search under vomiting, reflux or spitting up.
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