Management of Gastroesophageal Reflux Disease in Infants

Initial Management Approach

The American Academy of Pediatrics recommends lifestyle modifications, including feeding changes and positioning therapy, as the first-line approach for managing GERD in infants, rather than immediate pharmacologic intervention 1, 2
For breastfed infants, a 2-4 week maternal elimination diet that restricts at least milk and egg can help alleviate GERD symptoms, as milk protein allergy can mimic or exacerbate GERD symptoms 1, 3, 4
For formula-fed infants, switching to an extensively hydrolyzed protein or amino acid-based formula can help manage GERD symptoms 3, 5
Thickening feedings with up to 1 tablespoon of dry rice cereal per 1 oz of formula can help reduce reflux symptoms, but be aware that this increases caloric density 6, 7
Reducing feeding volume while increasing feeding frequency can help minimize gastric distension and alleviate reflux symptoms 2, 9
Proper burping techniques after feedings can help reduce reflux symptoms 1
Keeping the infant in a completely upright position when awake can help reduce reflux symptoms 6, 4

Upper endoscopy with esophageal biopsy is indicated in infants with poor weight gain who fail to respond to initial management, according to the American Academy of Pediatrics 1, 2
Warning signs such as bilious vomiting, gastrointestinal bleeding, consistently forceful vomiting, fever, abdominal tenderness or distension require immediate evaluation 5

Pharmacologic therapy should be reserved for infants who fail to respond to conservative measures, according to the American Academy of Pediatrics 2, 6
H2 receptor antagonists can be effective, but are limited by tachyphylaxis within 6 weeks 5
Proton pump inhibitors are more potent, but should be used cautiously due to concerns about overprescription 6, 5

Closely monitoring weight gain is critical in managing GERD in infants, as it is the primary outcome measure 1, 2
If no improvement is seen after 2 weeks of feeding changes, consideration should be given to evaluating for other causes of poor weight gain or referring to pediatric gastroenterology 3, 2, 9
A study found that 24% of formula-fed infants had resolved GERD symptoms after a 2-week trial of changing to a protein hydrolysate formula with thickening, avoiding overfeeding, avoiding seated positions, and avoiding environmental tobacco smoke 3, 7

Overdiagnosis and overtreatment with acid suppressants before trying conservative measures can occur, as cautioned by the American Academy of Pediatrics and the American Family Physician 6, 5
Failing to recognize the increased caloric density when thickening feeds can lead to excessive weight gain later 6
Relying solely on symptoms for diagnosis can be difficult in infants, as noted by the American Family Physician 5