In a healthy 2‑month‑old infant with spitting up after feeds, normal growth, soft abdomen, no hepatosplenomegaly, and normal labs, what is the most appropriate next step in management?

Management of Uncomplicated Regurgitation in a Healthy 2-Month-Old Infant

The most appropriate next step is to reassure the parents (Option B), as this infant demonstrates classic physiologic gastroesophageal reflux (GER) without any concerning features or complications. 1

Clinical Reasoning

This 2-month-old presents with the hallmark features of uncomplicated physiologic GER rather than gastroesophageal reflux disease (GERD):

• Normal growth parameters (50th percentile for height and weight) 1
• Benign physical examination (soft abdomen, no hepatosplenomegaly) 1
• No red flag symptoms (no bilious vomiting, no hematemesis, no blood in stool, no systemic illness) 1
• Normal laboratory studies (normal hemoglobin, WBC, platelets, urinalysis) 1

The American Academy of Pediatrics and NICE guidelines emphasize that regurgitation occurs daily in approximately 50% of all infants and is reported to resolve spontaneously by 12 months of age in 95% of cases. 1 This is a normal physiologic process that does not warrant investigation or pharmacologic treatment. 1

Why Other Options Are Inappropriate

Option A: Oral Proton Pump Inhibitor - NOT Indicated

Acid suppression therapy should be avoided in the "happy spitter" with isolated regurgitation and normal growth. 1 The guidelines explicitly state:

• PPIs are not indicated for uncomplicated regurgitation in infants with normal weight gain 1
• There is significant concern about overprescription of acid suppressants, particularly PPIs, in infants 1
• Acid suppression carries risks including increased susceptibility to community-acquired pneumonia, gastroenteritis, candidemia, and necrotizing enterocolitis in preterm infants 1
• Medication does not always resolve symptoms even when GERD is present, making empiric treatment problematic 1

Option C: Surgical Referral - NOT Indicated

Surgical intervention is reserved for severe GERD with complications that have failed medical management, such as:

• Failure to thrive despite optimal medical therapy 1
• Severe risk of aspiration with recurrent pneumonia 1
• Life-threatening complications unresponsive to pharmacologic treatment 2

This infant has none of these indications. 1

Option D: Abdominal CT - NOT Indicated

Imaging is not indicated for uncomplicated infant regurgitation with normal growth. 1, 3 The NICE guidelines specifically state: "Do not use upper gastrointestinal contrast radiology to diagnose or assess the severity of gastro-oesophageal reflux disease." 1

Imaging would only be appropriate if red flags were present, such as:

• Projectile or bilious vomiting (suggesting pyloric stenosis or malrotation) 4, 3
• Poor weight gain or failure to thrive 1, 3
• Hematemesis or bloody stools 1
• Abdominal distension or hepatosplenomegaly 1

Appropriate Management Strategy

The cornerstone of management for uncomplicated GER is parental education and reassurance: 1

• Explain the natural history: Regurgitation peaks at 4 months and resolves by 12 months in 95% of infants 1, 5
• Emphasize normal growth: The infant's growth at the 50th percentile confirms this is benign physiologic reflux 1
• Provide anticipatory guidance: Parents should understand this is self-limited and does not require treatment 1
• Schedule follow-up: Monitor growth parameters at routine well-child visits 1

When to Reconsider the Diagnosis

Return for re-evaluation if any of the following develop: 1

• Poor weight gain or crossing downward on growth curves (suggests GERD rather than GER) 1, 3
• Feeding refusal, irritability, or signs of pain with feeds (may indicate esophagitis) 1
• Respiratory symptoms (recurrent pneumonia, chronic cough, wheezing) 1
• Change to projectile or bilious vomiting (requires urgent evaluation for obstruction) 4, 3
• Blood in vomit or stool 1

Common Pitfalls to Avoid

The most critical error is overtreatment of physiologic GER with unnecessary medications. 1 The American Academy of Pediatrics explicitly warns against the "overprescription of acid suppressants, especially proton pump inhibitors" in the "happy spitter." 1

High-value, high-quality care in this scenario means providing detailed, repeated, and confident reassurance rather than initiating diagnostic testing or pharmacologic therapy. 1 This approach avoids medication risks, unnecessary costs, and parental anxiety while allowing the natural resolution of this self-limited condition. 1