Most new mothers worry that their babies are getting enough to eat. Poopy diapers can be reassuring, since nothing comes out the bottom unless something goes in the top. But when what goes in the top comes out the top, parents start to worry.

An article published in the March 2009 issue of Pediatrics revealed that two-thirds of healthy 4-month-old babies regurgitate (spit up) more than once a day. Even though regurgitation is common, 25 percent of parents think it’s abnormal. This explains why gastroesophageal reflux (GER) is one of the most common reasons parents give for pediatric office visits. GER is the term used to describe the back flow or reflux of food from the stomach into the esophagus during or after a meal. (The esophagus is the tube that carries food from the mouth to the stomach.)

In an effort to determine the prevalence of GER, a group of Italian researchers randomly selected 75 primary care pediatricians to participate in a prospective study. For a period of three months, from April 1 2004 to June 30 2004, the pediatricians were asked to record the regurgitation status of every infant seen in their office. All infants who met the selection criteria—one to 12 months of age, healthy and reportedly spitting up 2 or more times a day for at least 3 or more weeks were asked to participate in the study. Infants were reexamined every 2 months until the age of 24 months to see if the GER symptoms had lessened or worsened or if there had been a change in diagnosis (such as gastroesophageal reflux disease (GERD) or cow milk intolerance). During each visit, the infant was given a score of 0-31 based on 14 items including:

• Frequency and volume of regurgitation
• Feeding refusal
• Weight gain
• Irritability and crying
• Hiccups
• Back arching
• Respiratory symptoms

Results
Nearly 80 percent of the pediatricians agreed to participate in the study (59 out of 75). A total of 2642 infants were seen during the study period; 313 infants met the selection criteria and were enrolled in the study (12 percent). The average age of the infants was 5.6 months. Approximately one-third of the 313 infants (103) did not complete the study.

Treatment strategies included reassurance (72 percent of the infants), formula thickening (6 percent), antacids (9 percent), and medication to reduce gastrointestinal tract irritability (3 percent). Regurgitation disappeared in 88 percent of the children by 12 months of age and in all of the children by 24 months of age. Surprisingly, only one of the infants was diagnosed with GERD and one with cow milk protein intolerance, suggesting that both conditions are rare.

Does method of infant feeding make a difference?
Data show that breastfed infants stopped regurgitating sooner than formula-fed infants (8.2 months compared to 9.6 months). However, “breastfeeding” and “formula-feeding” were not defined. The overall prevalence of regurgitation (12 percent) was considerably lower than those reported in previous studies (41 to 67 percent). The lower rate may be explained by the fact that a stricter definition of regurgitation was used (2 or more episodes per day for 3 or more weeks).

Take home message

• The majority of babies spit up, so keep a burp cloth handy.
• GER is common but less so than previously thought.
• GER usually resolves by 18 months of age. If it doesn’t resolve, further evaluation may be needed.
• Cow milk intolerance and GERD are rare conditions.