Gastroesophageal Reflux in Infants: A Primary Care Perspective

Amy Lynn Arguin; Martha K. Swartz


Pediatr Nurs. 2004;30(1) 

In This Article

Management of Infants with Uncomplicated GER

Conservative management of the thriving infant with uncomplicated GER (the "happy spitter") is indicated if there are no complications. The pediatric nurse should reassure parents and provide anticipatory guidance regarding the natural course of GER in infants. Non- pharmacological interventions are generally all that are required, and an upper GI series is not required unless there are signs of gastrointestinal obstruction (Rudolph et al., 2001). Other diagnostic tests may be indicated if there are signs of poor weight gain, excessive crying or irritability, sleep disturbances, or respiratory problems (Rudolph et al., 2001). Sutphen (2001) suggests a non-aggressive approach for the vigorous, growing but irritable infant with frequent non-projectile regurgitation. This avoids overuse of tests and encourages parents to accept the infant's symptoms as normal variants of feeding patterns in infancy.

General Recommendations

Despite lack of randomized, controlled studies of non- pharmacological management of GER, life-style changes are generally recognized as the appropriate initial management of uncomplicated GER. In infants with GERD, life style changes are recommended in addition to medical therapy. Life style changes include the following modifications: (a) feeding schedule; (b) thickening of feedings; (c) positioning, and (d) formula changes.

Feeding Schedule Modification

In the overfed infant or infants fed large volumes at infrequent intervals, the volume of formula should be reduced (Brown, 2001; Jiang, Ewigman, & Danis, 2001). Increased frequency of feedings with small volumes has not been proven efficacious, is difficult to implement, and may create distress in a hungry infant. A modest reduction in volume may relieve pressure (Borowitz, 2002; Jiang et al., 2001). When babies cry for extended periods, they fill their stomachs with air, grunt, and strain, all of which tend to make reflux worse (Borowitz, 2002). During feedings, infants should be burped after every 1 to 2 ounces.

Thickened Feeds

Thickening feeds with rice cereal (one tablespoon per 2 to 4 ounces of formula) is associated with a decrease in the number of vomiting episodes, but does not improve reflux index scores (Rudolph et al., 2001). Jiang, Ewigman, and Danis (2001) report that thickened formula may reduce the frequency of regurgitation and total volume of emesis. It may also reduce time spent crying and increase time spent sleeping.

Rice cereal used as a thickener increases the caloric density of formula and may cause constipation. Thickened formulas also require enlarged nipple holes to feed, potentially resulting in greater ingestion of air or formula, which can favor regurgitation. Because rice cereal- thickened feedings have 150% of the caloric density of un-thickened feedings, only 65% of the volume needs to be fed per meal; thereby decreasing gastric volume (Orenstein, 2001). In an infant who is solely breast-fed, it is not possible to thicken the feeds unless the mother uses a breast-pump and then feeds the infant, which can be tedious and less desirable.

Commercially available pre-thickened formulas, such as Enfamil AR® which contains added rice, may be advantageous because they are nutritionally balanced, convenient, well tolerated, and the viscosity is two-to-threefold less than when rice cereal is added to formula. They can be given without an enlarged nipple hole. The viscosity increases in the acidic environment of the stomach (Brown, 2001; Sherman 2001).


Holding the infant in a head-elevated position for 20-30 minutes after feeding may reduce GERD (Farivar, 2001). The prone position has also been shown to reduce reflux, aspiration, and crying time and speed gastric emptying (Sherman, 2001). According to Borowitz (2002), after meals, the best position to place a baby with reflux is lying prone with the head of the bed raised about 30 degrees. Parents should be cautioned that placing the infant in a prone position should only be done when the child is awake and can be continuously observed. Prone positioning during sleep is only considered in unusual cases where the risk of death from complications of GER outweighs the potential increased risk of SIDS (Rudolph et al., 2001). The semi-supine position after feeding, such as when placing the baby in an infant car seat, exacerbates GER and should be avoided (Rudolph et al., 2001; Sandritter, 2003).

Formula change

Many parents and families attribute GER to sensitivities or allergies to milk or formula, and approximately one third of infants with symptoms of GER experience a formula change. However, there is a lack of controlled trials evaluating the efficacy of changing formulas in the management of uncomplicated GER, and parents may come to believe that their child has a disease or illness (Jiang et al., 2001).

True allergy to cow's milk or soy-based formulas occurs in less than 2% of infants and is unlikely to present with vomiting as the only symptom. However, in formula-fed infants, it is reasonable to try a protein hydrolysate or elemental formula, such as Alimentum®, Nutramigen®, or Pregestimil®, for a 2-week period if a cow's milk protein intolerance is suspected (Rudolph et al., 2001). In an infant who is breastfed, temporary elimination of cow's milk protein from the mother's diet may be tried. Temporary carbohydrate intolerance may occur with gastroenteritis, malnutrition, or in pre-term infants, but otherwise is rare in infancy (Brown, 2001).


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