What are the diagnosis and management options for newborns and infants with Gastroesophageal Reflux Disease (GERD)?

Diagnosis and Management of GERD in Newborns and Infants

Lifestyle modifications and conservative measures should be the first-line treatment for GERD in newborns and infants, with medications reserved only for those with confirmed GERD who fail conservative management. 1, 2

Diagnosis

Clinical Presentation

• Typical symptoms: Regurgitation, vomiting, irritability, feeding difficulties, arching of back during/after feeds
• Warning signs requiring further evaluation:
  • Poor weight gain or failure to thrive
  • Hematemesis or blood in stool
  • Recurrent pneumonia or respiratory symptoms
  • Forceful (projectile) vomiting
  • Bilious vomiting
  • Onset of vomiting after 6 months of age

Diagnostic Tests

1. pH/Multiple Intraluminal Impedance (MII) monitoring: Combined pH/MII testing is the test of choice to detect temporal relationships between specific symptoms and reflux of both acid and nonacid gastric contents 1

2. Upper endoscopy with biopsy: Indicated when:

   • Symptoms persist despite pharmacologic therapy
   • Poor weight gain, unexplained anemia, fecal occult blood
   • Recurrent pneumonia or hematemesis
   • To rule out other conditions (e.g., eosinophilic esophagitis) 1

3. Gastroesophageal scintigraphy: Not recommended for routine evaluation due to lack of standardized techniques and age-specific normal values 1

Management Algorithm

Step 1: Conservative Management (First-Line)

Feeding Modifications

• For breastfed infants:

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

• For formula-fed infants:

  • Trial of extensively hydrolyzed protein or amino acid-based formula 1, 2
  • Thicken formula with 1 tablespoon rice cereal per ounce (increases caloric density to 34 kcal/oz) 1
  • Consider commercially available anti-regurgitant formulas containing processed rice, corn, or potato starch 1
  • CAUTION: Do not use thickening agents in preterm infants (<37 weeks) due to risk of necrotizing enterocolitis 1

Positioning Therapy

• Keep infant upright for 20-30 minutes after feeding 2
• Prone positioning only when infant is awake and observed (due to SIDS risk) 1
• Avoid car seats or semi-reclined positions after feeding (can worsen reflux) 2
• For infants >1 year, prone positioning may be beneficial as SIDS risk decreases 1

Step 2: Pharmacologic Therapy (For confirmed GERD unresponsive to conservative measures)

Acid Suppressants

1. H2 Receptor Antagonists:

   • Ranitidine: 5-10 mg/kg/day divided in 2-3 doses (FDA approved for 1 month-16 years) 1
   • Famotidine: 1 mg/kg/day divided in 2 doses (FDA approved for 1-16 years) 1
   • Limitation: Tachyphylaxis within 6 weeks 2

2. Proton Pump Inhibitors (PPIs):

   • Omeprazole: 0.7-3.3 mg/kg/day (FDA approved for 2-16 years) 1, 3
   • Esomeprazole: 0.7-3.3 mg/kg/day (FDA approved for infants 1-12 months with erosive esophagitis) 1, 4
   • Administer: 30 minutes before meals 2
   • Side effects: Increased risk of community-acquired pneumonia, gastroenteritis, candidemia, kidney problems (tubulointerstitial nephritis), C. difficile infection, bone fractures with long-term use 2, 3

3. Antacids: Limited evidence for on-demand use; generally not recommended as first-line therapy 1

Step 3: Surgical Intervention (Last Resort)

• Nissen fundoplication: Reserved for infants with:
  • Intractable symptoms unresponsive to medical therapy
  • Life-threatening complications of GERD 1, 4

Important Considerations

Differential Diagnosis

• Cow's milk protein allergy: Often mimics or coexists with GERD in 42-58% of infants 4
  • Trial of extensively hydrolyzed formula or maternal elimination diet for 2-4 weeks 2

Monitoring and Follow-up

• Track weight gain and growth
• Assess for symptom improvement (reduced regurgitation, improved feeding, decreased irritability)
• Watch for constipation with rice cereal thickening 2

Common Pitfalls

1. Mistaking normal physiologic GER ("happy spitters") for pathologic GERD requiring medication 4
2. Using partially hydrolyzed formulas instead of extensively hydrolyzed formulas for cow's milk protein allergy 2
3. Failing to recognize that most infant reflux resolves by 12 months of age without intervention 4, 5
4. Overuse of acid suppressants, particularly PPIs, without confirmed GERD diagnosis 1

Remember that 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 4.