Spitting

Why is my baby spitting?

Many babies spit up a bit of milk. It is not a cause for concern as long as the baby is growing well. Normally, the baby remains happy while spitting and the milk just flows out of the mouth. The baby may be bothered a bit if more milk flows and the baby chokes a little, or the milk comes out of the nose. Spitting happens because compared to adults, babies take in large volumes and their swallowing tubes and stomachs are smaller. Also, the valve that keeps food in the stomach is not as firm. Spitting usually begins by six weeks of age and ends by one year. If your baby is still spitting after one year of age or has red, black, or green spit-up, talk to your health-care providers.

A) Describing spitting

A normal baby spitting.

It is normal for the stomach (gastric) contents to occasionally flow backwards into the swallowing tube (esophagus). The medical name for this is gastroesophageal reflux (GER).

This can happen in all humans – old and young. Reflux allows the stomach to off-load pressure. Reflux episodes are short and don’t cause any problems for most of us. Babies tend to reflux more than adults because they have a relatively small stomach and a short esophagus.

Reflux happens into the esophagus but sometimes the stomach contents will rise further up the esophagus and leak out of the baby’s mouth. This is called spitting or posseting. Regurgitation is the medical term. Spitting is generally a good sign since it can indicate that a mother has a good milk supply.

Spitting is not the same as vomiting and there are ways to tell the two apart. A small number of babies have gastroesophageal reflux disease (GERD). A baby with GERD is sick, whereas GER is normal spitting.

B) Reasons for spitting

There are several reasons for spitting:

  • Babies take in a lot of milk at each feed relative to their size in the first year.
  • Babies have a shorter esophagus and smaller stomach than adults.
  • The valve system that keeps food in the baby’s stomach from passing back into the esophagus is less firm.

All of these result in milk flowing backward from the stomach, through the esophagus, and into the baby’s mouth. Sometimes if the spit-up is large, it even comes out through the nose.

Breastfed babies are less likely to spit than infant formula-fed ones (Leung 2019).

C) Spitting appearance and patterns

1) The appearance of spit-up

The spit-up may look like regular milk or curdled milk. Curdled milk looks like a clear liquid with small, cheesy flecks or lumps. The curdled appearance is caused by digestion in the stomach, where acid separates the milk into curds and whey.

2) Typical spitting behaviour

Babies may spit frequently, occasionally, or never. When a baby spits, you may notice:

  • No change in the baby’s behaviour after spitting.
  • The spit-up is only a small part of the feed.
  • The spit-up does not travel far.
  • The baby is happy before, during, and after spitting.
  • There is generally no sound.
  • Spitting can happen at the same time as a burp.
  • Spitting often happens with the second hiccup.

In normal spitting, the baby stays happy and the milk just flows out of the mouth. Occasionally, there may be more milk, the baby may choke a little, or the milk may come out of the nose. This may bother the baby a bit.

3) Milk coming out of the baby's nose

In some babies, milk drips out of the lower nostril when they are breastfed on their side as in in the cradlecross-cradle, or side-lying position. They usually aren’t bothered by this and happily keep breastfeeding. This dripping is not common but nothing to worry about if the baby is otherwise well. 

A very small number of breastfed babies who leak milk out of their noses have abnormalities in the roof of their mouth (submucosal cleft palate) or of their feeding and swallowing processes (Rai 2015; van den Engel-Hoek 2015). They may not grow well or may show other signs of illness.

D) Timing of spitting

Spitting is normal for many babies. It is most common after a feed, when lying down, or when pressure is put on the tummy. However, it can happen any time, even hours after a feed.

A baby may start to spit soon after the mother’s milk comes in, when the amount of milk dramatically increases.

If babies are going to spit, they will usually start by six weeks of age. Half of babies between 0 and 3 months spit at least once a day and up to 40% of babies aged 3 to 4 months spit, but less than 5% are still spitting by 13 to 14 months (Martin 2002; Nelson 1997).

E) Treatment of spitting

Spitting is a common concern for families. One study (Nelson 1997) reported that more than one-fifth of mothers were worried about their baby’s spitting at six months of age. As long as the baby is growing well and generally happy when fed and held, spitting is not a cause for concern.

There is no treatment for spitting, and the only harm it does is creating more laundry. It should not be treated with medication or by putting cereal in the baby’s bottle.

Some mothers are concerned that the baby’s spitting is caused by not enough burping. This is generally not the case. Rather spitting is normal and burping should be used to help settle pain caused by the baby’s tummy cramps and excess air in the tummy.

Families may also incorrectly assume that spitting is due to food allergies which may lead to weaning, or to changing formula types.  

F) Abnormal spitting

Please talk to your health-care providers you notice any of the following. 

1) Bloody spitting

The spit-up should not be bloody, brown, or black as this means there is blood present. Such blood may originate from the mother’s milk or nipples.

Blood in spit-up can come from the baby and be caused by:

  • Wounds in the esophagus or stomach
  • Bleeding disorders such as low vitamin K levels
  • Anatomic abnormalities
  • Tumours
  • Vomiting blood that was swallowed during delivery

The spit-up should not be yellow or green. This indicates that there is bile present in the spit-up and a sign that the baby is ill. 

2) Excessive spitting

Rarely, babies are sick and spit excessive amounts because of an abnormality in the digestive system. Such babies may not grow well. If the baby’s spitting seems excessive, please consult your health-care provider. You may wish to make a video of the baby’s behaviour for your provider to watch. 

3) Spitting past the age of one

Babies do not tend to spit past twelve months of age.

References

Leung AK, Hon KL. Gastroesophageal reflux in children: an updated review. Drugs Context. 2019 Jun 17;8:212591

Martin AJ, Pratt N, Kennedy JD, et al. Natural history and familial relationships of infant spilling to 9 years of age. J Pediatrics 2002; 109:1061-67Martin AJ, Pratt N, Kennedy JD, et al. Natural history and familial relationships of infant spilling to 9 years of age. J Pediatrics 2002; 109:1061-67
 
Nelson SP, Chen EH, Syniar GM, et al. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997 Jun;151(6):569-72

Rai GS, Sarawagi R, Sharma S, et al. An infant with nasal regurgitation since birth and failure to thrive. J Clin Diagn Res. 2015 Apr;9(4):TD03-4
 
van den Engel-Hoek L, de Groot IJ, de Swart BJ, et al. Feeding and Swallowing Disorders in Pediatric Neuromuscular Diseases: An Overview. J Neuromuscul Dis. 2015 Nov 20;2(4):357-369