In a 2‑month‑old infant who regurgitates after every feed but has normal growth, a soft non‑distended abdomen, no hepatosplenomegaly, normal laboratory studies and negative stool occult blood, what is the most appropriate next step in management?

Management of Uncomplicated Gastroesophageal Reflux in a 2-Month-Old Infant

Reassure the parents that this is physiologic gastroesophageal reflux (the "happy spitter"), which requires no investigation or specific treatment and will resolve by 12 months of age in 95% of infants. 1

Clinical Reasoning

This infant demonstrates classic uncomplicated physiologic GER rather than gastroesophageal reflux disease (GERD):

• Normal growth parameters (50th percentile for height and weight) indicate adequate caloric intake despite regurgitation 1, 2
• Absence of red flags: No projectile vomiting, bilious emesis, hematemesis, blood in stool, abdominal distension, hepatosplenomegaly, or systemic features 1
• Normal laboratory studies exclude metabolic, infectious, or hematologic causes 1
• Effortless regurgitation after feeds is the hallmark of physiologic reflux, not GERD 1, 3

Why Other Options Are Inappropriate

Oral Proton Pump Inhibitor (Option A) - Incorrect

• Acid suppression is explicitly contraindicated for isolated overt regurgitation without complications 1
• PPIs should be avoided in the "happy spitter" and are reserved for documented esophagitis or failure to thrive 1, 3
• Overuse of medications in infants with uncomplicated reflux provides no benefit and carries risks including increased infection rates 1, 4

Surgical Referral (Option C) - Incorrect

• Surgery is reserved only for life-threatening complications or failure of medical therapy in true GERD 3, 2
• This infant has no indication for surgical evaluation: normal growth, no respiratory complications, no esophagitis 1

Abdominal CT (Option D) - Incorrect

• Imaging is not indicated for uncomplicated infant reflux with normal growth 1, 5
• CT exposes the infant to unnecessary radiation without diagnostic benefit 5
• Upper GI contrast studies are indicated only for bilious vomiting, dysphagia, or suspected anatomic abnormalities—none of which are present 1, 5

Management Approach

Primary intervention is parental education and reassurance 1, 3:

• Explain that 70-85% of infants have regurgitation within the first 2 months, and this resolves without intervention in 95% by 12 months of age 3, 2
• Emphasize that continued normal weight gain confirms adequate nutrition despite visible regurgitation 1, 2

Optional conservative measures (if parents desire intervention) 1:

• Smaller, more frequent feedings 2
• Feed thickening agents (rice cereal) may reduce visible regurgitation but do not change acid exposure 1, 2
• Upright positioning for 20-30 minutes after feeds while awake 2

Critical Red Flags Requiring Re-evaluation

Return immediately if any of these develop 1, 5:

• Projectile or bilious (green) vomiting 1, 5
• Blood in vomit or stool 1
• Poor weight gain or weight loss 1, 5
• Persistent irritability, back arching, or feeding refusal suggesting pain 3, 6
• Respiratory symptoms (chronic cough, wheezing, apnea) 3, 4
• Abdominal distension 1, 5

Follow-Up

• Regular weight checks are essential to confirm continued normal growth trajectory 5, 2
• Most regurgitation resolves by 12 months without any intervention 1, 3, 2

The correct answer is B - Reassure the parents.