If baby burp cloths are in heavy rotation at your house, you might wonder whether all’s well in your baby’s GI tract. But spitting up, also called gastroesophageal reflux (GER), is a typical part of babyhood. If your infant is eating well, growing, and not in pain, there’s no reason to worry about it.

“Stomach content coming back up into the esophagus is a normal physiologic process in everyone — even adults — that happens multiple times per day,” says Andrew Singer, MD, assistant clinical professor of pediatric gastroenterology at University of Michigan Health C.S. Mott Children’s Hospital.

Reflux happens often in babies because the muscle that separates their esophagus from their stomach (the lower esophageal sphincter) isn’t yet strong enough to keep contents inside their tummy. And with feedings every 2-3 hours, there’s almost constantly something there to come up.

“It’s just very easy for things to sneak up into the esophagus where they’re not intended to be,” Singer says.

As babies get older, the lower esophageal sphincter stays tightly closed except when they swallow, and food and liquids stay in the stomach where they belong.

Run-of-the-mill spitting up shouldn’t cause any upsetting symptoms in your baby. So if you notice these worrisome signs, it could mean their reflux has enough acid that it’s damaging the lining of your baby’s esophagus, a condition called gastroesophageal reflux disease (GERD):

  • Weight loss
  • Forceful (projectile) spitting up
  • Spit up that’s green, yellow, bloody, or looks like coffee grounds
  • Refusal to eat
  • Bloody poop
  • Trouble breathing or constant cough
  • Spitting up that suddenly starts after 6 months old
  • Fussiness after eating

“If you have an infant who spits up after a feed, and then they fuss for 5-10 seconds afterwards, that’s not that big of a deal,” Singer says. “But if every time they spit up, they just seem like they go from totally calm to really uncomfortable and in pain, that suggests that there may be a problem.”

Ani Perrault of Winnipeg, Manitoba, Canada, says her infant daughter was a generally happy baby most of the time — until she spit up. “She exorcist-style projectile-vomited everywhere constantly, and often wailed about it,” she says.

Another clue that things weren’t right was her baby’s acidic-smelling breath. Perrault took her to the pediatrician to get it checked out.

“His first response was that if she was gaining weight well it was ‘more of a laundry problem’ than anything else,” she says. “But when it didn’t improve after starting solids, we got a [GERD] diagnosis.”

Whether your baby has GERD or is simply spitting up often, you can help reduce reflux by paying attention to how and when you feed them. Try these tips:

  • Feed your baby smaller amounts more often. Be sure they’re taking in enough for healthy growth, but don’t overfeed. “Often parents feed a fussy baby because they think the problem is hunger,” Singer says. “But if kids are eating too much, that increases the likelihood that reflux is going to occur.”
  • Burp baby mid-feed. Pause at natural points during feeding and get a good burp out of your baby. “Babies will swallow a lot of air when they’re feeding, and that competes for room in the stomach,” Singer says. “The more full and distended the stomach gets, the more likely things are to come up.”
  • Hold off on tummy time after feeding. Keep your baby upright for about 20-30 minutes post-meal. That way gravity can help hold things down while digestion happens.
  • Thicken baby’s formula. If your baby is at least 4 months old, ask your pediatrician about the adding a small amount of infant cereal to their bottle. “The idea is that if things are a little bit thicker, they’ll stay down in the stomach a little bit better,” Singer says.

Although there are a couple of over-the-counter acid reflux medications for infants, they won’t treat typical reflux. But they may help reduce some symptoms of GERD caused by acid damage in the esophagus.

“Medication for reflux only serves to decrease the amount of acid that the stomach is secreting in the first place,” Singer says. “It doesn’t actually keep reflux from happening.”

Perrault says ultimately if your baby is clearly unhappy or uncomfortable, don’t hesitate to tell your doctor. You may catch a potential problem that could have long-term effects on your baby’s diet. As an older toddler her daughter couldn’t tolerate many textures in her food. And though she doesn’t take daily medication for GERD today at age 9, she does still need an antacid a few times a week.

“In our case, our baby was always ahead of the curve for height and weight and she ate well, even when it looked like she was vomiting most of it back up,” Perrault says. “But she was late meeting milestones, and it has definitely had a lasting impact on her relationship with food.”