How to manage gastroesophageal reflux disease (GERD) in a three-month-old infant?

From the Guidelines

To manage gastroesophageal reflux disease (GERD) in a three-month-old infant, start with lifestyle modifications, including positioning techniques, feeding changes, and thickening agents, as these are recommended by the most recent guidelines 1.

Key Recommendations

• Positioning techniques: Keep the baby upright for 20-30 minutes after feedings and elevate the head of their crib or bassinet by about 30 degrees using a wedge under the mattress.
• Feeding changes: Feed smaller amounts more frequently rather than large feedings, and burp your baby thoroughly during and after each feeding.
• Thickening agents: Consider using anti-reflux formulas or adding rice cereal to formula (1-2 teaspoons per ounce) after consulting with your pediatrician.

Additional Considerations

• For breastfeeding mothers, consider eliminating potential trigger foods from your diet, such as dairy, caffeine, chocolate, and spicy foods, for 1-2 weeks to see if symptoms improve.
• Avoid overfeeding and try to maintain a calm feeding environment.
• If these measures don't help, consult your pediatrician about medications like famotidine (Pepcid) or ranitidine, which reduce stomach acid production.

Important Notes

• Most babies outgrow reflux by 12-18 months as their digestive systems mature and they spend more time upright.
• Reflux occurs because the lower esophageal sphincter muscle between the stomach and esophagus is still developing in infants, allowing stomach contents to flow backward, especially when babies spend much of their time lying down.
• The guidelines from the National Institute for Health and Care Excellence (NICE) recommend considering simple, cheap interventions, such as minor feed modifications or thickening agents, when possible, and avoiding acid-suppressing drugs in isolated overt regurgitation 1.

From the FDA Drug Label

The pharmacokinetics of lansoprazole were studied in pediatric patients with GERD aged less than 28 days and one to 11 months. Lansoprazole was not found to be effective in a US and Polish four week, multicenter, double-blind, placebo-controlled, parallel-group study of 162 patients between one month and less than 12 months of age with symptomatic GERD based on a medical history of crying/fussing/irritability associated with feedings who had not responded to conservative GERD management (i.e., nonpharmacologic intervention) for seven to 14 days. There was no difference in the percentage of responders between the lansoprazole pediatric suspension group and placebo group (54% in both groups). Based on the results of the Phase 3 efficacy study, lansoprazole was not shown to be effective Therefore, these results do not support the use of lansoprazole in treating symptomatic GERD in infants

The management of gastroesophageal reflux disease (GERD) in a three-month-old infant should not include lansoprazole as it was not found to be effective in this age group 2.

• Nonpharmacologic interventions should be considered as the first line of treatment.
• The FDA drug label does not provide guidance on alternative treatments for GERD in infants less than one year of age. It is recommended to consult with a pediatrician or a gastroenterologist for further guidance on managing GERD in a three-month-old infant.

From the Research

Managing Gastroesophageal Reflux Disease (GERD) in Infants

To manage GERD in a three-month-old infant, several strategies can be employed:

• Lifestyle Changes: Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux 3.
• Feeding Modifications: Lower-volume feedings, thickening agents (i.e., rice cereal), antiregurgitant formula, extensively hydrolyzed or amino acid formulas can be used to treat reflux in infants 4, 5.
• Body Position Changes: Body position changes while awake can help alleviate reflux symptoms in infants 4.
• Dietary Changes: In breastfed infants, eliminating cow's milk and eggs from the mother's diet may help reduce reflux symptoms 3, 4.
• Pharmacologic Treatment: Histamine H2 receptor antagonists and proton pump inhibitors are the principal medical therapies for GERD, and can be effective in infants, although the evidence is of low quality 4, 5.
• Surgical Treatment: Surgical treatment, such as Nissen fundoplication, is available, but should be considered only when medical therapy is unsuccessful or is not tolerated 3, 4.

Warning Signs and Diagnostic Tests

It is essential to recognize warning signs that may indicate a more serious condition, such as:

• Choking, gagging, coughing with feedings or significant irritability 3
• Forceful vomiting, bilious or projectile vomiting, hematemesis 5, 6
• Failure to gain weight, recurrent regurgitation, and respiratory complications 6 Diagnostic tests, such as endoscopy, barium study, multiple intraluminal impedance, and pH monitoring, may be used when there is diagnostic uncertainty or alarm symptoms are present 4, 5, 6.