How to manage an infant with feeding difficulties and reflux?

Management of Infants with Feeding Difficulties and Reflux

For infants with feeding difficulties and reflux, a comprehensive approach involving early gastroenterology referral, proton pump inhibitor therapy, and specialized feeding therapy is strongly recommended to prevent failure to thrive and complications.

Initial Assessment and Diagnosis

• Infants with feeding difficulties and reflux often present with symptoms including poor feeding, regurgitation, irritability during feeds, arching of the back, and failure to thrive 1, 2
• Distinguish between physiologic gastroesophageal reflux (GER) which is effortless, painless, and doesn't affect growth versus gastroesophageal reflux disease (GERD) which includes troublesome symptoms or complications 1
• Warning signs requiring prompt intervention include weight loss, poor growth, feeding refusal, and respiratory complications such as choking or aspiration 1

Medical Management

• Refer to a pediatric gastroenterologist early in infancy for comprehensive evaluation and management of feeding difficulties, gastroesophageal reflux, and poor growth 1
• Diagnostic evaluation may include:
  • Swallowing studies to assess for dysphagia and aspiration risk 1
  • pH studies, upper GI series, and possibly endoscopy as recommended by the gastroenterologist 1
• Medical treatment options:
  • Proton pump inhibitors (PPIs) are the first-line pharmacologic treatment for GERD 1
  • Initial trial of PPI for 2 weeks; if symptoms improve, continue for 8-12 weeks 1
  • Monitor for relapse after discontinuation; if symptoms return, consider consultation with pediatric gastroenterology 1
  • Avoid prokinetic agents (such as bethanechol, baclofen, erythromycin) due to insufficient evidence supporting their routine use 1

Feeding Strategies

• Implement feeding therapy at the first sign of oral aversion 1
• Consider referral to a feeding specialist (speech-language pathologist or occupational therapist) for evaluation and recommendations 1, 3
• Feeding modifications may include:
  • Thickening feeds to reduce reflux episodes 1
  • Modifying dietary texture based on swallowing assessment 1
  • Positioning infant on left side after feeding to reduce reflux episodes 4
  • Maintaining upright position after meals 2

Nutritional Support

• Regular monitoring of growth parameters (height, weight, head circumference) at each visit 1
• For infants with failure to thrive despite feeding modifications:
  • Consider assisted feeding via nasogastric tube or gastrostomy tube, which may be necessary in 40-50% of severe cases 1
  • If significant gastroesophageal reflux is present, nasoduodenal or gastro-jejunal feeding may be preferable to nasogastric feeding to minimize aspiration risk 1
  • Avoid long surgical procedures like Nissen fundoplication due to high anesthesia risk unless absolutely necessary 1

Interdisciplinary Approach

• Establish an interdisciplinary feeding team including:
  • Pediatrician/primary care physician
  • Gastroenterologist
  • Speech-language pathologist
  • Occupational therapist
  • Dietitian/nutritionist 3, 5
• This team approach addresses the medical, motor, and behavioral aspects of feeding difficulties 3
• Regular reassessment and adjustment of the feeding plan as the infant develops 5

Caregiver Support and Education

• Provide parents with education about:
  • Recognizing signs of reflux and aspiration
  • Proper feeding techniques
  • Positioning strategies
  • Realistic expectations regarding progress 5
• Acknowledge the stress on parents and provide appropriate psychosocial support 6

Common Pitfalls to Avoid

• Overuse of medications in "happy spitters" with uncomplicated GER that is not affecting growth 1
• Delaying referral to specialists when weight loss or significant feeding difficulties are present 1
• Failing to distinguish between physiologic GER and pathologic GERD requiring intervention 1
• Not addressing oral aversion early, which can lead to long-term feeding problems 1, 6
• Pursuing surgical interventions without adequate trial of medical and feeding therapies 1

By following this structured approach to managing infants with feeding difficulties and reflux, clinicians can effectively address both the underlying medical issues and the feeding challenges, ultimately improving outcomes related to growth, nutrition, and development.