Rice Cereal Thickening for Infant Formula

Recommended Dosing

The American Academy of Pediatrics recognizes adding up to 1 tablespoon of dry rice cereal per 1 oz of formula as a reasonable management strategy for otherwise healthy full-term infants with gastroesophageal reflux disease (GERD) or gastroesophageal reflux (GER), with a recommended starting point and titration based on symptom response 1, 2

Thickening 20 kcal/oz formula with 1 tablespoon rice cereal per ounce increases the energy density to 34 kcal/oz, a 70% increase in calories, which can lead to excessive weight gain with long-term use, so monitoring growth parameters closely is necessary 1, 2
Consider commercially available anti-regurgitant formulas as an alternative, which contain processed rice, corn, or potato starch without the excessive caloric density, for infants with GERD or GER 1, 2

Never use thickened feedings in preterm infants born before 37 weeks gestation, particularly those currently hospitalized or discharged within the past 30 days, due to the association with necrotizing enterocolitis, as warned by the FDA against using commercial thickening agents like SimplyThick in this vulnerable population 1, 2

Thickened feedings decrease visible regurgitation but do not reduce the actual number of reflux episodes in infants with GERD or GER, and may be used in combination with other strategies such as avoiding overfeeding and environmental tobacco smoke 1, 2
In one study, 24% of formula-fed infants had complete resolution of GERD symptoms after 2 weeks using protein hydrolysate formula thickened with 1 tablespoon rice cereal per ounce, combined with avoiding overfeeding and environmental tobacco smoke, demonstrating the potential effectiveness of this intervention for infants with GERD 1, 2

Reserve thickened feedings for infants with documented GERD symptoms, not "happy spitters" who are growing well without complications, and always try this conservative approach before considering pharmacologic therapy with acid suppressants, according to the American Academy of Pediatrics 1, 2

The American Academy of Pediatrics recommends keeping the infant completely upright for 10-20 minutes after feeding for adequate burping, and breastfeeding should be maintained whenever possible, with maternal elimination of cow's milk and eggs if needed 3
Discontinuing breastfeeding in favor of thickened formula should be avoided, and upright positioning in caregiver's arms is preferred after feeding, as recommended by the American Academy of Pediatrics 3

The American Academy of Pediatrics suggests considering commercially available anti-regurgitant formulas containing processed rice, corn, or potato starch, which avoid excessive caloric density, before thickening with rice cereal, although no specific citation is provided in the article, a similar recommendation is found in 3