What is the recommended thickener for breast milk in infants with Gastroesophageal Reflux Disease (GERD)?

Recommended Thickener for Breast Milk in Infants with GERD

Rice cereal at a dose of 1 tablespoon per ounce of expressed breast milk is the recommended thickener for breast milk in infants with GERD, but should only be used in full-term infants over 37 weeks gestation. 1

Understanding Infant GERD and Thickening Options

Gastroesophageal reflux disease (GERD) in infants presents with symptoms including feeding refusal, recurrent vomiting, poor weight gain, irritability, sleep disturbance, and respiratory symptoms such as coughing, choking, and wheezing 1. While many infants experience physiologic reflux ("happy spitters"), GERD represents a more severe condition requiring intervention.

First-Line Approaches Before Thickening

Before considering thickening breast milk, implement these strategies:

1. Maternal diet modification: A 2-4 week trial of maternal exclusion diet that restricts at least milk and egg is recommended for breastfeeding infants with GERD symptoms 1
2. Feeding adjustments: Reduce feeding volume while increasing feeding frequency 1
3. Positioning: Keep infants in completely upright position when awake (prone positioning only when observed and awake) 1

Breast Milk Thickening Protocol

When the above measures fail to provide relief:

For Full-Term Infants (≥37 weeks):

• Add 1 tablespoon of dry rice cereal per 1 oz of expressed breast milk 1
• This approach is recognized as a reasonable management strategy for otherwise healthy infants with GERD 1

Important Cautions:

• NEVER use thickening agents in premature infants (<37 weeks gestation) due to risk of necrotizing enterocolitis 1, 2
• The FDA has specifically warned against using commercial thickeners like "SimplyThick" in premature infants 1

Effectiveness and Considerations

Thickened feedings have been shown to:

• Decrease observed regurgitation rather than actual number of reflux episodes 1
• Help resolve symptoms in approximately 24% of infants with GERD when combined with other interventions 1

Nutritional Impact:

• Adding rice cereal increases the energy density of feeds from 20 kcal/oz to approximately 34 kcal/oz 1
• This increased caloric density may lead to excessive energy intake with long-term use 1

Commercial Alternatives:

• Commercially available anti-regurgitant formulas (containing processed rice, corn, potato starch, guar gum, or locust bean gum) may be an option for formula-fed infants but not for breast milk 1, 2

Monitoring and Follow-up

• Monitor for improvement in GERD symptoms (reduced regurgitation, improved feeding, decreased irritability)
• Watch for constipation, which can occur with rice cereal thickening
• If symptoms persist despite thickened feeds and other conservative measures, consider referral to pediatric gastroenterology for further evaluation 1

Common Pitfalls to Avoid

1. Using thickeners in premature infants - associated with necrotizing enterocolitis 1
2. Overlooking cow's milk protein allergy - can mimic GERD symptoms and may co-exist in 42-58% of infants with GERD 3
3. Relying solely on thickening - a comprehensive approach including positioning and feeding modifications is more effective 1
4. Overuse of acid suppressants - there is significant concern about overprescription of acid suppressants, especially proton pump inhibitors 1

Remember that GERD symptoms often peak at approximately 4 months of age and typically resolve by 1 year of age in most infants 4.