What medications are used to treat acid reflux in infants?

Medications for Acid Reflux in Infants

For infants with acid reflux, medications should only be used for confirmed gastroesophageal reflux disease (GERD) that fails to respond to conservative management, not for uncomplicated physiologic reflux which affects most infants. 1, 2

Understanding Infant Reflux

Gastroesophageal reflux (GER) is a normal physiologic process occurring in 50-70% of healthy infants, typically resolving without intervention by 12 months of age. It becomes GERD when reflux causes troublesome symptoms or complications including:

• Feeding or sleeping problems
• Failure to thrive
• Chronic respiratory symptoms
• Esophagitis
• Hematemesis
• Apnea or apparent life-threatening events

First-Line Approach: Conservative Management

Before considering medications, conservative approaches should be tried:

• Feeding modifications:

  • Smaller, more frequent feedings
  • Thickening formula with 1 tablespoon rice cereal per ounce (avoid in preterm infants)
  • Using pre-thickened anti-regurgitant formulas

• Positioning strategies:

  • Holding infant upright for 20-30 minutes after feeding
  • Left side positioning when awake and supervised

• For breastfed infants: 2-4 week maternal elimination diet (milk and eggs)

• For formula-fed infants: Trial of extensively hydrolyzed protein or amino acid-based formula

Medications for Confirmed GERD

When conservative measures fail and GERD is confirmed, medications may be considered:

1. Histamine-2 Receptor Antagonists (H2RAs)

• Options:

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

• Considerations:

  • Begin working within 30 minutes
  • Effects last approximately 6 hours
  • Tachyphylaxis can develop within 6 weeks
  • Less effective than PPIs for erosive esophagitis

2. Proton Pump Inhibitors (PPIs)

• Options:

  • Omeprazole: 0.7-3.3 mg/kg/day (FDA-approved for ages 2-16 years) 3
  • Lansoprazole: 0.7-3.0 mg/kg/day (FDA-approved for ages 1-17 years) 4
  • Esomeprazole: 0.7-3.3 mg/kg/day (FDA-approved for ages 1-17 years)

• Important note: PPIs are not FDA-approved for infants under 1 year for GERD. Lansoprazole specifically was not found to be effective in infants less than 1 year of age in clinical trials 4.

3. Antacids

• Limited evidence for effectiveness in infants
• Generally considered relatively benign but should be used cautiously

Important Cautions and Considerations

1. Medication overuse: There is increasing evidence of inappropriate prescriptions for PPIs in the pediatric population 1, 2.

2. Diagnostic confusion: GERD symptoms may overlap with cow's milk protein allergy in 42-58% of infants 5.

3. FDA warnings: Recent black box warnings have been issued for certain medications, particularly promoters of gastric emptying and motility 1.

4. PPI risks: Long-term PPI use may increase susceptibility to infections, bone fractures, and other side effects 3.

5. Limited evidence: Efficacy data for acid-suppression therapy in infants is based on low-quality evidence 6.

When to Refer to a Specialist

Consider referral to pediatric gastroenterology when there are:

• Bilious or projectile vomiting
• Gastrointestinal bleeding
• Persistent symptoms despite appropriate therapy
• Failure to thrive
• Respiratory complications

Conclusion

For most infants with reflux, reassurance and conservative measures are sufficient. Medications should be reserved only for those with confirmed GERD that fails to respond to conservative management. When medications are necessary, they should be used at the lowest effective dose for the shortest duration needed.