What are the treatment options for gastroesophageal reflux disease (GERD) in infants?

Treatment Options for Gastroesophageal Reflux Disease (GERD) in Infants

Lifestyle modifications should be the first-line treatment for GERD in infants, with pharmacological therapy reserved only for those with documented complications or who fail conservative management. 1

Initial Management: Lifestyle Modifications

Feeding Modifications

• For breastfed infants:

  • 2-4 week trial of maternal exclusion diet that restricts at least milk and egg 1
  • Reduce feeding volume while increasing feeding frequency 1

• For formula-fed infants:

  • Switch to extensively hydrolyzed protein or amino acid-based formula 1
  • Consider thickened feedings:
    • Add up to 1 tablespoon of dry rice cereal per 1 oz of formula 1
    • Or use commercially thickened (added rice) formulas 1
    • CAUTION: Do not use thickening agents in premature infants (risk of necrotizing enterocolitis) 1

Positioning Strategies

• Keep infants in completely upright position after feeding 1
• Left side positioning after feeding may reduce reflux episodes 2
• IMPORTANT: Prone positioning should ONLY be used when infant is awake and observed due to SIDS risk 1
• Avoid seated positions 1

Pharmacological Treatment (Second-Line)

Medications should be reserved for infants with:

• Documented GERD complications (esophagitis, poor weight gain, respiratory symptoms)
• Failure to respond to conservative management 1

Medication Options:

1. Histamine-2 Receptor Antagonists (H2RAs)

   • Options: Ranitidine (5-10 mg/kg/day divided in 2-3 doses) 1
   • Limitations: Can cause tachyphylaxis within 6 weeks 1

2. Proton Pump Inhibitors (PPIs)

   • More potent than H2RAs 1
   • Dosing: Omeprazole 0.7-3.3 mg/kg/day 1
   • FDA approved for infants: Esomeprazole for 1-12 month olds with erosive esophagitis 3
   • Should be given ~30 minutes before meals 1

3. Antacids

   • Generally not recommended for chronic use in infants due to side effect risks 1

Important Cautions

• Risks of acid suppression therapy:

  • Increased risk of community-acquired pneumonia
  • Gastroenteritis
  • Candidemia
  • Necrotizing enterocolitis in preterm infants 1
  • Kidney problems (tubulointerstitial nephritis) 4
  • Severe diarrhea (C. difficile infection) 4

• Prokinetic agents:

  • Insufficient evidence to support routine use 1
  • Adverse effects include drowsiness, restlessness, and extrapyramidal reactions 1

Surgical Management

• Fundoplication is reserved for infants with:
  • Intractable symptoms unresponsive to medical therapy
  • Life-threatening complications of GERD 1
  • Particularly consider in infants with bronchopulmonary dysplasia who have deteriorating pulmonary function 5

Diagnostic Considerations

Before escalating treatment, rule out conditions that mimic GERD:

• Cow's milk protein allergy (overlaps with GERD in 42-58% of infants) 3
• Eosinophilic esophagitis 1
• Neurologic disorders 3
• Infection 3

Upper endoscopy with biopsy is indicated in infants who:

• Fail to respond to pharmacologic therapy
• Have symptoms of poor weight gain
• Have unexplained anemia or fecal occult blood
• Experience recurrent pneumonia or hematemesis 1

Remember that approximately 70-85% of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95% of infants by 1 year of age 3, 6.