Diagnosis
H&P
Reflux vs. Reflux Disease (GER vs. GERD)
Risk factors:
Common presentation:
Complications:
DDx and Etiology.
Treatment of Reflux in infants
Nonpharmacologic tx (lifestyle & dietary changes)
-Position changes while awake,
-Reduce feeding volume and increase feeding frequency,
-Thicken the formula – Add 1 tbsp rice cereal per oz of formula
-Formula fed-infants: Anti-regurgitant formula (extensively hydrolyzed or amino acid formulas)
-Breastfed infants – Eliminate cow’s milk and eggs from the mother’s diet.
Pharmacologic tx
-If lifestyle and dietary therapy for 2-4 weeks don’t work, try acid suppression with PPI or H2 blocker for 4 weeks.
-If symptoms improve, continue acid suppression tx for 8-12 weeks before reevaluating. If no improvement, consider alternative diagnosis and refer to a pediatric gastroenterologist.
–Drug choices and doses.
**Don’t use medications in infants that have regurgitation that is effortless, painless, and not affecting growth.
Indications for starting pharmacotherapy(PPI, H2 blockers) include when the infant is not growing well or appears to be in pain.
“Gastroesophageal reflux is very common in infants. Reflux in infants peaks at 4 months of age, and two-thirds of infants regurgitate at least once a day at this age. The incidence declines dramatically in the next few months, and by 1 year of age less than 5% of infants regurgitate on a daily basis. If the infant is healthy and growing normally, reassurance is appropriate (SOR C). Conservative measures are recommended if the reflux causes distress (SOR C). Such measures include placing the infant on her side or prone while awake to reduce reflux. However, infants should not be placed prone while sleeping, to prevent SIDS. Appropriate conservative measures also include smaller, more frequent feedings, the addition of thickening agents such as rice cereal to formula, and changing to amino acid formulas if infants are allergic to cow’s milk protein. If conservative measures and time do not alleviate the symptoms, a 4-week trial of H2-blockers or proton pump inhibitors can be tried. The American Academy of Pediatrics and the Society of Hospital Medicine (Pediatric) recommend not routinely treating reflux with medication. Imaging, such as esophagogastroduodenoscopy, is not routinely used in the initial workup of reflux in infants. It is reserved for recalcitrant cases, atypical symptoms, or complications (SOR C).“ ABFM Critique
Reference / Further Reading
Pediatrics. 2013 May;131(5):e1684-95. Gastroesophageal reflux: management guidance for the pediatrician. https://www.ncbi.nlm.nih.gov/pubmed/23629618
Am Fam Physician. 2014 Mar 1;89(5):395-397.
Am Fam Physician. 2015 Oct 15;92(8):705-717. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children.