What is the appropriate work‑up and treatment for gastro‑oesophageal reflux in an infant?

Work-up and Treatment for Infant Reflux

Initial Assessment: Distinguish Physiologic GER from Pathologic GERD

Most infants with frequent regurgitation have benign physiologic reflux that requires only parental reassurance and education—not diagnostic testing or medication. 1

Key Clinical Context

• Physiologic gastroesophageal reflux (GER) peaks at 4 months of age, affecting approximately 50% of infants, then resolves spontaneously in 90-95% by 12 months. 2
• GER becomes gastroesophageal reflux disease (GERD) only when it causes troublesome symptoms severe enough to merit medical treatment or leads to complications. 1
• The diagnosis is primarily clinical, based on history and physical examination—not on testing. 1, 3

Red Flags Requiring Immediate Investigation

Actively look for warning signs that suggest serious underlying conditions beyond simple reflux: 1, 4

• Bilious vomiting (suggests malrotation or obstruction)
• Consistently forceful or projectile vomiting (suggests pyloric stenosis)
• Hematemesis or blood in stool (suggests esophagitis, gastritis, or other GI pathology)
• Poor weight gain or failure to thrive (suggests GERD or other pathology)
• Feeding refusal with significant irritability (suggests esophagitis)
• Abdominal distension or tenderness (suggests obstruction or other acute abdomen)
• Fever, lethargy, hepatosplenomegaly (suggests systemic illness)
• Neurologic signs (bulging fontanelle, macro/microcephaly, seizures)
• Recurrent lower respiratory infections or apnea (suggests aspiration)

If any red flags are present, proceed immediately to diagnostic work-up rather than empiric management. 4

---

Diagnostic Work-up

For Uncomplicated Physiologic Reflux (No Red Flags)

No diagnostic testing is indicated. 1, 2

• Avoid upper GI series, pH monitoring, and endoscopy in typical physiologic reflux. 2
• These tests lead to false-positive diagnoses and unnecessary interventions. 4

For Suspected GERD or Presence of Red Flags

Upper GI series (barium study): 1

• Use to assess anatomy and exclude structural abnormalities (malrotation, pyloric stenosis, strictures)
• Do NOT use to diagnose or assess severity of GERD—it is unreliable for this purpose 1

24-hour esophageal pH monitoring: 4, 5

• Most accurate test for quantifying acid reflux (near 100% specificity when pH <4 for >5% of monitoring time) 4
• Indicated for high-risk infants with failure to thrive, recurrent respiratory infections, or neurologic impairment (e.g., cerebral palsy) 4
• Provides temporal correlation between reflux episodes and respiratory events (desaturations, apnea) 4
• Essential before considering surgical intervention 4

Upper endoscopy with esophageal biopsy: 1

• Reserved for suspected esophagitis, treatment failure, or to exclude other diagnoses (eosinophilic esophagitis, cow's milk protein allergy) 1
• Carries anesthesia risk; not a first-line diagnostic tool 4

Multichannel intraluminal impedance monitoring: 1

• Can detect both acid and non-acid reflux episodes
• Consider when pH monitoring is negative but symptoms persist 1

---

Treatment Algorithm

Step 1: Conservative Management for Physiologic GER

All infants with uncomplicated reflux should receive parental reassurance and conservative measures first. 1, 2

Parental Education and Reassurance

• Explain that regurgitation peaks at 4 months and resolves by 12 months in 90-95% of cases 2
• Emphasize this is a benign, self-resolving condition requiring no medication 1

Feeding Modifications

For breastfed infants: 1, 3

• Trial a 2-4 week maternal elimination diet excluding cow's milk and eggs (addresses potential cow's milk protein allergy, which coexists in 42-58% of infants with reflux symptoms) 1, 6

For formula-fed infants: 1, 3

• Consider extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 1
• Thickening feedings with rice cereal may reduce regurgitation, but avoid in preterm infants due to increased risk of necrotizing enterocolitis 1, 3
• Reduce feeding volume while increasing feeding frequency 1

Positioning Strategies

• Keep infants upright or in left lateral position after feeding (only when awake and supervised) 1, 7
• Never use prone positioning for sleep due to SIDS risk 3
• Avoid secondhand smoke exposure 2

---

Step 2: Pharmacologic Therapy (Only for Confirmed GERD)

Acid suppression therapy should NOT be prescribed for physiologic reflux—it increases risk of pneumonia, gastroenteritis, and candidemia without proven benefit. 2, 4

When to Consider Pharmacologic Therapy

• Documented erosive esophagitis on endoscopy 8
• Persistent troublesome symptoms (feeding refusal, poor weight gain, significant irritability) after 4-6 weeks of conservative management 1
• High-risk populations (neurologic impairment, repaired esophageal atresia) with objective evidence of GERD 4

Proton Pump Inhibitors (PPIs)

PPIs are the most potent acid suppressants and superior to H2 antagonists for confirmed GERD. 1

• Esomeprazole is FDA-approved for erosive esophagitis in infants 1-12 months 6
• Dose 30 minutes before meals for optimal efficacy 1
• Important caveat: PPIs increase risk of community-acquired pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis in preterm infants 1, 4

H2 Receptor Antagonists

• Effective but limited by tachyphylaxis within 6 weeks 1
• May increase risk of liver disease and gynecomastia with long-term use 1
• Consider as alternative to PPIs in mild-moderate GERD 3

Prokinetic Agents (Domperidone, Metoclopramide)

Current guidelines conclude there is insufficient evidence to justify routine use of prokinetic agents in infants. 8, 6

• If used, domperidone dose is 0.2-0.3 mg/kg three times daily 8
• Significant concern: adverse effects include drowsiness, restlessness, extrapyramidal reactions, and potential cardiac risks 1, 8
• Benefits do not outweigh risks in most cases 1

---

Step 3: Surgical Intervention (Highly Selective)

Fundoplication is reserved only for carefully selected patients who have failed medical therapy or have severe risk of aspiration. 1

Indications for Surgery

• Life-threatening complications despite maximal medical therapy 6
• Severe GERD with documented aspiration in high-risk infants (e.g., neurologic impairment) 4
• Objective confirmation of severe reflux on pH monitoring 4

Pre-surgical Requirements

• Document reflux severity with 24-hour pH monitoring 4
• Endoscopic evaluation to confirm esophagitis 4
• Assess for delayed gastric emptying (may require concurrent gastrostomy or pyloroplasty) 4

Important Surgical Caveat

• Fundoplication carries significant morbidity (gas bloat, dysphagia, wrap failure) 1
• Role in neonates and young infants is unclear and should be reserved for exceptional cases 6

---

Common Pitfalls to Avoid

1. Over-diagnosing GERD in infants with normal physiologic reflux and prescribing unnecessary PPIs 1, 2
2. Using upper GI series to diagnose GERD—it only assesses anatomy, not reflux severity 1, 4
3. Prescribing acid suppression without objective evidence of GERD in high-risk infants with red flags—these patients need pH monitoring first 4
4. Assuming all irritability is reflux—rule out cow's milk protein allergy, constipation, neurologic disorders, and infection 6
5. Using thickened feeds in preterm infants due to necrotizing enterocolitis risk 1
6. Routinely prescribing prokinetic agents despite insufficient evidence and significant adverse effects 8, 6