From the Guidelines
For a 2-month-old, full-term, formula-fed infant with uncomplicated GERD who vomits after every feeding, the next appropriate intervention would be to try a thickened formula, as this has been shown to reduce symptoms of GERD in infants 1. This can be achieved by adding 1 teaspoon of rice cereal per 1-2 ounces of formula, or by using a commercially available pre-thickened formula such as Enfamil AR or Similac for Spit-Up. Some key points to consider when implementing this intervention include:
- Implementing feeding modifications, including smaller, more frequent feedings (2-3 ounces every 2-3 hours instead of larger amounts less frequently) 1
- Ensuring proper burping during and after feedings
- Keeping the infant upright for 20-30 minutes after feeding
- Positional therapy during sleep, such as elevating the head of the crib by about 30 degrees using a wedge placed under the mattress (never place pillows directly in the crib) 1 These conservative measures work by increasing the density of feedings, which helps them stay down in the stomach, and by using gravity to minimize reflux. It is also important to note that medications such as acid suppressants (H2 blockers or proton pump inhibitors) are not recommended as first-line therapy for uncomplicated GERD in infants this age, as they often resolve spontaneously by 12-18 months of age as the lower esophageal sphincter matures and the infant spends more time in an upright position 1. In addition to these measures, it may be helpful to consider changing to an extensively hydrolyzed protein or amino acid–based formula, as this has been shown to be effective in reducing symptoms of GERD in formula-fed infants 1. Overall, the goal of these interventions is to reduce the symptoms of GERD and improve the quality of life for the infant, while also minimizing the risk of complications and promoting healthy growth and development.
From the Research
Diagnosis and Treatment of Uncomplicated GERD in Infants
The infant in question has been diagnosed with uncomplicated Gastroesophageal Reflux Disease (GERD) and is experiencing vomiting after every feeding. According to 2, a thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER.
Non-Pharmacological Interventions
For non-complicated reflux, no intervention is required for most infants, and effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux 2. Conservative treatments for gastroesophageal reflux disease in infants include:
- The use of thickening agents or extensively hydrolyzed or amino acid-based formulas in formula-fed infants 3
- Maternal elimination of dairy for infants who are fed breast milk 3
- Feeding schedule modifications, thickened feeds, changes in positioning, or a trial of formula change 4
- Body position changes while awake, lower-volume feedings, thickening agents (i.e., rice cereal), antiregurgitant formula 5
Pharmacological Interventions
If the infant does not improve with conservative measures, pharmacologic treatment, including an empiric trial of acid-suppression therapy for 4 to 8 weeks, may be considered 3. Histamine H2 receptor antagonists and proton pump inhibitors are the principal medical therapies for GERD, and are effective in infants, based on low-quality evidence, and in children and adolescents, based on low- to moderate-quality evidence 5.
Monitoring and Follow-up
It is essential to monitor the infant's symptoms and growth, and to refer to pediatric specialists if complications or warning signs occur, such as failure to gain weight, irritability, swallowing difficulties, regurgitation, and respiratory complications 6.