EP 29: Baby Spit Up Explained: What's Normal, Red Flags to Watch For, and When to Call the Doctor

What if your baby’s constant spit-up is normal, even when it looks like a lot? In this episode of Nutrition for the Early Years, host Dr. Liz explains why babies spit up, how their growing digestive systems play a role, and why many cases are simply a messy laundry problem. She shares how to tell common reflux from warning signs such as poor growth, swallowing trouble, and true projectile vomiting. Dr. Liz also clears up fears about babies choking during sleep, explains why back sleeping remains safest, and discusses why antacids are not always helpful. With reassurance and practical guidance, this episode helps parents understand when to call the doctor, when to keep watching, and why they do not need to feel guilty for having a spitty baby.

What You’ll Learn:

• Why is spit-up common in young babies
• How infant anatomy and digestion affect reflux
• Why the amount of spit-up is not always important
• Why babies should still sleep on their backs
• Which symptoms may need medical attention
• Why reflux medicine is not always needed
• How to feel more confident caring for a spitty baby

Episode highlights:
(1:36) Why does frequent spit-up feel so overwhelming
(3:08) When spit-up commonly begins
(4:26) Why does spit-up often look like more than it is
(6:43) How baby anatomy causes mechanical spit up
(9:27) Safe sleep, choking fears, and back sleeping
(10:40) What normal reflux can look like
(12:29) Poor growth and other warning signs
(13:48) Projectile vomiting and pyloric stenosis
(15:15) Swallowing, airway, and stool concerns
(16:11) What studies say about reflux and antacids
(18:56) When reflux needs added support
(20:48) Final red flags and reassurance for parents

NEW COURSE! "Read the Pattern: Feeding Your Baby 0–4 Months" — because a healthy relationship with food starts earlier than most people think. Course Link!

Disclaimer: This podcast is for educational purposes only, not medical advice.

Transcript

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Welcome back to Nutrition for the Early Years podcast. I'm your host, Dr. Liz Daniels, your nutrition-focused pediatrician and your guilt-free guidance for feeding your family well. I am so excited to share with you today what we're going to talk about is just a number one topic that we have in the first year of life. And it tends to be everywhere. I'm talking about spit up. You thought I was going to say poop, I bet, but but really, it's one of the most stressful things that parents deal with. And I have a lot of experience in my own life with my own babies, but also with the thousands of families I've helped over the years. And I'm hoping today to walk you through kind of the guardrails of like what's normal, what's not, when to be worried, and really and truly, like the things that, you know, a lot of families I think don't know just in general about baby physiology, or maybe you do, but it's helpful to hear that in context with how their nutrition is changing as they're growing, just so you can kind of have some framework for why it's okay for there to be such a big range. And we're also going to talk a little bit about when to call the doctor and like when it's not normal. Welcome back to the Nutrition for the Earliers podcast with me, your host, Dr. Liz Daniels. I'm a nutrition first kind of pediatrician, and this podcast is for the parent who's second-guessing their grocery cart, worrying if their kid is going to end up with the same food struggles that they once had. I love getting into the weeds of what kids actually need and then putting it into context of where they're at in growth and development so you can let go of the shame and guilt and focus on what actually moves the needle together. Let's get into it. So your baby is spitting up, like exorcist style, and you need to know what to do. It can feel overwhelming when they're puking on the clothes, on the furniture, in the car seat. It can be every spit up or just once a day. And the unpredictability of it can be really irritating because you never know what it's causing it, and more importantly, who's causing it. At the end of the day, telling you just not to worry isn't helpful enough. We need to know why. We need to understand. Today we're going to walk through the ins and outs of what's normal with spit-up and when to be worried. I'm going to start by saying that when I first had my babies, I had read all the books and felt like I'd been around enough babies to know that Spitup is normal. Like, don't freak out, Liz. It's going to be fine. But then when it happened over and over, and especially when my baby was fussy with it and crying, I had a really hard time trusting that when my doctor would tell me everything's okay, that everything was really okay. It probably took me four or five appointments to really believe them that nothing needed to change. And I see a lot of parents go through the same kind of stress. My goal today is to give you more kind of backbones understanding for why babies spit up so much. So that if you're in the camp that I was in, you can rest easy knowing sometimes it's okay to not have to fix it. And sometimes there are things we need to do, right? So we're going to walk through those. And hopefully after this, you'll feel a lot more confident that you know which camp you're in. And you know, here's the thing it often starts for a lot of babies around two weeks. And once that happens, usually it's okay if it's a little bit. But if you were like my baby and you spit up kind of like every single feed and it became a lot, and then more volume as the baby got bigger, the worry starts to increase and starts to amplify. And the internet only makes it worse, right? Because every spit up is suddenly a silent reflux or some dairy problem or a reason that you need to go on a formula or something in your diet you need to change, and you have a thousand different things with a thousand tabs open. And the problem here is that it's hard to discern what's real and what's not because babies change from feeding to feeding. And that is normal. Our expectation, though, as parents is that they're going to be predictable, that at week one, they're going to behave a certain way. Week two, they maybe are going to be, you know, pretty consistent. We might read in books that, okay, there's going to be a growth spurt at this one particular week. And so we expect it. But then our babies play us and it's the set week before or the week after. The problem here is that that unpredictability is really what's frustrating for so many parents. Because if you could have a direct relationship or have a direct association with, oh, here's the problem, then it's easier to adjust and move on and not take it personally, like you're doing something wrong with your baby. I was in that camp. Okay. And then the other part to this is that the volume of how much actually comes out when they throw up is like it looks like a whole lot. And in reality, it's often not. So, you know, you can take a couple of tablespoons and dump it on the floor, and it actually makes a pretty big puddle. So the same way, when a baby spits up, they'll tell me, parents will often tell me, Oh, is there a whole bottle? Like, you don't really know. And I don't say that in judgment. I just say that in that like volume displacement is really difficult to quantify. And you don't have to, because it doesn't change anything if it was an ounce or three ounces. It doesn't actually change the diagnosis at all. The volume isn't what matters. It's really that kind of the pattern overall and the things that I will talk you through, like that are really the worry signs and the red flags, aren't volume-based. So you can let that one go. It's also genuinely hard to read because babies are maturing. So their digestive tract is actually maturing in real time. And their ability to break down both breast milk and formula matures with them. And in the very beginning, those digestive enzymes really haven't started being there in great abundance. And breast milk in the very beginning is colostrum. As it matures, both the transit time and the types of proteins that are in abundance in the breast milk shift to support the growing baby as it should. However, sometimes those digestive enzymes aren't really there yet. And so it can end up creating a little bit of digestive issues. And sometimes parents think, well, I have to change something in my diet, just not being aware that it's already happened and the milk is going to help the baby to help the baby's digestive tract mature as well. So it's okay. In other words, keep it going. Don't try to fix it yet. Now, it's not all in your head because there are differences that are happening that you can't quite see. And the other piece to this is that I think the guidance over the years has shifted quite a bit. And we know more about how babies are maturing. We also have more formula options. And so I think because there's more options, I think a lot of parents feel like they have to keep going from one to the other. And that's a trap I would love to help you avoid. So let's talk about what it actually is and what it's not. Okay. So in in most babies, when we're talking about spitup, we're really talking about what I kind of jokingly like to call a laundry problem. And this means that it's mechanical. So mechanical spit up. Sometimes this mechanical spit-up, you know, we expect is going to resolve really quickly, but I like families to know that it actually can take a very long time, sometimes like nine months before babies are really over it. And so you might be in this, you know, change your clothes every five minutes camp for a while. Okay. I know I was. Now, you and I, our esophagus goes down and attaches to the stomach with this little gate in between called the lower esophageal sphincter. And as food goes down the esophagus, it the sphincter opens up, their gate opens up, food goes through, the gate closes, and then food stays in the stomach when the stomach is churning around and helping break it down before it goes down into the intestines through another gate called the pyloric sphincter. Anatomy lesson aside, what I like to communicate is that you and I have a longer esophagus than babies do. Our bellies, our stomachs, are actually sort of tilted on the side. And babies, it's kind of more like a little globe right underneath their short esophagus. And that gate that's supposed to keep the liquid down inside the belly, it's closed for us, but it's not usually closed for a lot of babies. It can be, and that's great fortune if that's you, otherwise you're not listening to this podcast. But if that's open, a little bit of fluid, even with a little bit of force, can go right back up. Now, think of it this way: when the food goes through the esophagus, that gate's supposed to close. And if it doesn't, and the stomach churns, you have pressure and it's gonna go in both directions, even when your belly is digesting the food. So families will tell me, well, they ate and like three hours later they spit up. Isn't that a problem? That's gotta be reflux. Not necessarily. That might be that you just had some milk that hadn't fully emptied and it's okay. Well, it's curdled and it's gotta be bad. Not necessarily. You have gastric juices, and now that you have mature breast milk or you have intact protein on your formula, the casein that's in there, especially and whey, but casein primarily is going to curdle and create those curds as soon as it hits a lower pH. That's normal physiology. Thank goodness our body has those things. It just doesn't feel good when it comes up and it's stinky. So the fact that it's curdled, the fact that it's four hours after you fed, or that it's every time you eat, still normal. I'm sorry. The next part here is that, you know, families will think often, well, I'm really worried that they're gonna lay on their back and that they're gonna choke or that they're gonna be unsafe because if they throw up when they're asleep, it's gonna be really dangerous for them, right? Actually, it's a lot safer to be on your back. Part of the reason that we have the back to sleep campaign. But bear in mind that your breathing tube, your trachea is in the front, your esophagus is in the back. So when you lay back on your back and the liquid comes up through the esophagus into the mouth or out, and then whatever's left over comes back down. Gravity will pull it down into the esophagus, which is at the bottom. If you're on your back, if you're on your side or your belly or at an incline, you are actually at higher risk for aspirating in those positions. So, really and truly, even for a refluxy baby, the safest position is on our back to sleep. It's noisy, and that's the point. We want to know when our babies are having to gag or they're having trouble with spitting up. And, you know, that is okay. It's important to learn how to suction their mouth if you need support with that, but it's really common to see that. I know it can be really scary for parents to see a baby gag or struggle. It really, really can. So I'm not trying to minimize that, but I simply like families to know that the safety of them being on their back is actually greater. And that's a good thing. So, okay. Spit up is gonna last a long time. It can be every feed, it can be once a day, it can be curdled, it can come out their nose, it can be a little bit or a lot, and all still normal. So then what really is reflux? When I'm talking about reflux, I think about it being mechanical. And reflux is present in most babies. I mean, honestly, like according to literature, it's about 40% of the time. But, you know, the key here is that I think when we think about GERD, you and I can think about maybe the night we had too much Mexic food and margaritas and we had reflux and it hurt. And we're often afraid that our babies are hurting when they're throwing up. And I would love to tell you that I don't think that's the case. You know, they can cry for all of their communication needs. And yes, there are some people who are like, the cry was like the tongue was shaped like this, and so that's what the cry means. And maybe. But I would also tell you the babies cry for a lot of different reasons. And when you actually study this, it is not a good indicator of reflux or pain. And parents swear it, they're like, I know it was pain. You're like, uh, I don't want to tell you, but we might not know it was pain. Be open, be curious. So to summarize, I do feel like a lot of the time, whether it's physiologic, normal, or a lot of reflux, it still is just a laundry problem. Meaning, in that category of babies who are puking maybe a little bit or a lot, it's okay. And it's actually something that we don't have to chase or fix because time is the treatment. And that is something we get to after we've made sure we're not missing anything else. So, what are the things that we really want to make sure we're not missing? Well, there's kind of a couple of categories. Number one, growth. If our baby truly isn't growing, like we're not getting enough weight on because we're throwing up so much. And this is exceedingly rare, but it does happen. If that's you, then we need to know and we need to investigate and we need to look for reasons for that happening. In the next podcast, I'm going to talk about calmic protein allergy, which could be one of those reasons. But the other thing that I think about is actually projectile vomiting, which also goes with not growing well. And this is different from what often parents describe as projectile vomit. I had this just happen last week where a family came in and they were like, we had two projectile vomits in the last couple of days. Guess how old the baby was? 16 days. And so right on time, which was perfect. But I said, Okay, so tell me about this. How far did it go? What set the scene for me, paint the picture, walk me in the room? And it kind of came out in like I was sitting here and it hit the chair over there. And they showed me about an arm's length away, so maybe a foot and a half. Okay, that is pretty far. That was a lot to clean up. Um, like, yeah, and then it happened again the next day. Okay, well, so I like to, I'd like to know distance because for me, it's not the only metric, but it is a helpful metric. I think about pyloric stenosis. Remember how I said there's two gates at the one at the top of the stomach and one at the bottom of the stomach? Well, the one at the bottom of the stomach can actually, for some genetic reasons, sort of thicken after birth to the point where it becomes like a barricade instead of being a gate, and it can be so thick of a muscle that very little milk can go downward. And everything else comes back up. And so in those scenarios, babies actually don't grow because they're puking everything up and it can be really pragmatic. We want to make sure that we treat that and address that and diagnose it properly and well. So, in this particular scenario, it's important we actually did do an ultrasound to make sure everything's okay. Because what if it's uh only what I would really call forceful vomiting as opposed to true projectile vomiting today? But what if in a week from now, which is how long it would take to get the ultrasound, it becomes projectile vomiting, right? And so we were reassured things are really good. But knowing that it's not true projectile vomiting, so I use that five feet mark as sort of like my threshold to say that's my real worry and that's my real definition for projectile vomit. Forceful vomit is forceful vomit. And it can happen especially when you have external force from patting on the back or from gravity from being on your back. Totally okay and not necessarily something we need to chase. That's just physics. Now, the other guardrail that I like to say is not normal is if there are airway issues going on. If our babies are actually struggling with swallowing, that's a little different. And this one is nuanced and definitely takes individual attention and care. If our baby's refusing a bottle, if we're struggling with really getting breastfeeding going and we're worried that there's weird sounds coming from the baby or, you know, other things going on, it's important to get some people in our corner. So that's a key one. And then the other category here is um, you know, what do we need to do? Like if we're struggling and we are seeing, you know, blood in the stool or mucus in the stool, those are not like go to the emergency room things, actually. Believe it or not, those are like call your doctor, we'll figure it out kind of things. And um, that's really important to know as well. Again, more on Calmut proteinol in the next um podcast. But but I like families to walk through that. Now, I want to tell you in a little bit more didactic way. There's a couple studies that I really love to reference when I think about spitup. And the reason is because it kind of makes us like question ourselves as clinicians. And then this is a good thing. In the mid-2010s, like 2016 to 19, there were a handful of really good, well-done studies in the NICUs looking at this in a little bit greater detail. And they studied NICU babies and said, okay, we know that their gates, their sphincters, are less developed. Their intestinal mucosa is less developed, so they're at higher risk for reflux. And traditionally, a lot of these babies will get put on like an antacid because the assumption is that they have a lot of reflux. And the reason this is an important question is because there are some other really interesting studies that suggest antacids are not ideal for little babies because the histamine pathway is really important. We do a lot of things with that. And it's not just for producing gastric juices, it's important. And so the question becomes: if we aren't truly in pain, if we are not hurting any of our esophageal structures with that reflux, then is there value in treating it and chasing it with an antacid? And this is a very good question. I was in the camp of babies who got put on an antacid because it was a spitty baby. And then by the time my third baby rolled around, we knew not useful. Don't bother. Just get a lot of laundry detergent. Okay. So, but where I'm going with this that is that in the NICU babies, they actually studied, you know, not only their pH, but the physical symptoms that we have used forever to say this baby has reflux and doesn't. And the internet will swear by it knows what reflux looks like. But like, for example, the arching of the back or the sour burps and the spit up that looks like this or like that, and blah, blah, blah, or the fussy and the crying, all of those things that we've been told for years are reflux symptoms, and that I believed to a T and took to my doctor numerous times saying, My baby has reflux. And she said, Yes, he's a normal baby. Um and what I want to give you the takeaway here is that they found in this study that the pH probes actually didn't correlate with those symptoms very well at all. It doesn't mean that the babies didn't have reflux. It means that in our littlest of babies, our NICU babies, reflux is actually not always acidic. And this is my anchor for you when you get worried about the pain, because pH probes are really not a reliable indicator of reflux. The bottom line is if you think your baby is having reflux, they probably are having reflux. The question becomes: is it something that they're going to outgrow, which they inevitably will, or is this something that they need additional support with? And we are not good as parents or clinicians at being objective enough to really know by looking at a baby that they're truly in pain or not. And this gives us permission to allow that cry to mean something else other than pain. Which also means that if your baby is crying and they're fussy and they're spitty, sometimes they're just crying and they're fussy and they're spitty. Because that like doesn't feel good. And that's okay. And you can still hold them and you don't have to fix that to still support them. Does it mean that we don't care? No. But I want you to be absolved of guilt that you're missing something or you're doing something wrong or that you're failing your baby because you didn't give them an antacid or because you didn't advocate for them in some special way with some special formula. We're going to talk more about that in the next podcast. But, you know, you can go down the rabbit hole of trying to figure out some of these things. And again, like we come to the happy spitter because we know they're happy, or even just like in my case, my boys weren't always happy when they were spitting up. But it wasn't that there was an allergy or that there was something else there. And for most of my patients that are in that camp, it's really good to know that you're not missing something else and you have permission to have a spitty baby because they won't be that way forever. Now, not that you have to, but I found one thing that was rather cathartic was taking pictures of it. So I have lots of pictures of my baby's puke, more as something that I now laugh at and remind myself, like it's okay and it's normal. And again, we our guardrails are are we growing? Do we have something that's true projectile vomiting? Do we have um, you know, problems with our growth or with our digestion in a way that is consistent and and and worrisome? And if we're not, then we can talk through the dairy elimination in the next podcast. We're gonna talk about trying to make sure it's not Kelmut protein allergy. But if you go down that road and you're like, okay, it's not, there it is. That's your permission. And it's okay. Know that they will outgrow it. And it takes a long time. And I think that that permission is something is just really helpful to hear. I honestly wish that I'd had that when I had little babies because I felt like as a mom, like, and I think a lot of parents will feel this way that like there's just something that they're missing out on, or something that they don't know, and they're afraid that they're hurting their baby or that they're, you know, not giving their baby something that they need to be giving them. So it's okay. That's your permission. So, you know, your goal isn't necessarily to stop every spit up or to intervene. Our goal is to keep a baby comfortable while they're growing through that and to know that you're not failing them as a parent. Hope that that helps. Thanks so much for listening all the way to the end. We'll see you guys next week.