pediatrics
Gastroesophageal Reflux in Infants
Treatment of Reflux in Infants
Modifying feedings Positioning Sometimes acid-suppressive therapy Rarely surgery For infants with gastroesophageal reflux, the only necessary treatment is to reassure caregivers that the symptoms are normal and will be outgrown. Infants with GERD do require treatment, typically beginning with conservative measures. Thickened feedings Smaller, more frequent feedings Sometimes hypoallergenic formula For breastfed infants, changing the mother's diet As a first step, most clinicians recommend reviewing proper feeding techniques (eg, volume of feedings, proper burping, positioning); if correction of technique is not enough, feedings can be thickened by adding 10 to 15 mL (1/2 to 1 tbsp) of rice cereal to 30 mL of formula. Thickened formula seems to reflux less, particularly when the infant is kept in an upright position for 20 to 30 minutes after feeding. Thickened formula may not flow through the nipple properly, so the nipple orifice often must be enlarged to allow adequate flow. Providing smaller, more frequent feedings helps keep the pressure in the stomach down by giving the stomach less volume and the chance for better emptying and often minimizes the amount of reflux. However, it is important to maintain an appropriate total amount of formula per 24-hour period to ensure adequate growth. In addition, burping the infant after every 1 to 2 oz can help decrease gastric pressure by expelling the air the infant is swallowing. If conservative measures fail, a hypoallergenic formula should be used in formula-fed infants for 2 to 4 weeks because these infants may have a food allergy. Hypoallergenic formula (hydrolyzed protein formulas) can even be helpful for infants who do not have a food allergy by improving gastric emptying. Cow's milk protein allergy can occur in breastfed infants and can be a cause of GERD. A trial of placing the mother on a strict cow's milk protein–free diet for several weeks may be helpful. If symptoms do not respond, referral to a gastroenterologist is recommended. All children should be kept away fromcaffeineand tobacco smoke. After feeding, infants are kept in an upright, non-seated position for 20 to 30 minutes (sitting, as in an infant seat, increases gastric pressure and is not helpful). For sleeping, left lateral positioning and elevation of the head of the crib are no longer recommended because of safety concerns. Regardless of the presence of reflux, the only recommended sleeping position for infants is supine, which has been shown to reduce the risk of Sudden Unexpected Infant Death (SUID) and Sudden Infant Death Syndrome (SIDS) and other sleep-related death. Three classes of drugs have been used in infants with GERD who do not respond to feeding modification and positioning: Proton Pump Inhibitors (PPI) H2 Blockers None Promotility medications The North American and European specialty societies recommend that infants and children with GERD unresponsive to feeding and positioning modifications be given a proton pump inhibitor (PPI) ( Treatment references ). If PPIs are unavailable or cannot be used, an H2 blocker can be given. These medications are may be tried before doing surgery on infants who are unresponsive to acid-blocking medications ( Treatment references ). Of the other agents, Infants with severe or life-threatening complications of reflux that are unresponsive to medical therapy can be considered for surgical therapy. The main type of antireflux surgery is fundoplication. During this procedure, the top of the stomach is wrapped around the distal esophagus to help tighten the lower esophageal sphincter. Fundoplication can be very effective at resolving reflux but has several complications. It can cause pain when infants vomit (eg, during acute gastroenteritis), and if the wrap is too tight, infants may have dysphagia. If dysphagia occurs, the wrap can be dilated endoscopically. Some anatomic causes of reflux/vomiting also may have to be corrected surgically. 1.Rosen R, Vandenplas Y, Singendonk M, et al: Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.J Pediatr Gastroenterol Nutr66(3):516-554, 2018. doi: 10.1097/MPG.0000000000001889 2.Tillman EM, Smetana KS, Bantu L, Buckley MG: Pharmacologic Treatment for Pediatric Gastroparesis: A Review of the Literature.J Pediatr Pharmacol Ther21(2):120-32, 2016. doi: 10.5863/1551-6776-21.2.120 