Treat Babies with Reflux Conservatively

Conservative therapies are associated with improvement in infants with symptoms that suggest gastroesophageal reflux.

Many infants with symptoms that suggest gastroesophageal reflux (GER) receive acid-reducing medications, despite questions about their necessity and efficacy. To assess the benefit of nonpharmacologic interventions, investigators used the validated Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) to compare GER symptoms in 37 infants (age range, 4–43 weeks) at baseline and 2 weeks after their parents were taught conservative treatment measures. Infants at five U.S. outpatient pediatric sites were included in the study if they had a minimum I-GERQ-R score consistent with GER disease (score >16 out of 42).

Conservative measures consisted of using hypoallergenic formula, thickening formula with dry rice cereal, eliminating cow’s milk and soy milk from the diet of breast-feeding mothers, preventing overfeeding, avoiding seated and supine positioning after feeding, and avoiding exposure to tobacco smoke. After 2 weeks, symptom scores improved in 78% of infants, with 59% achieving a clinically meaningful decline of at least five points. In 24% of infants, scores normalized to below the cutoff for GER disease. Symptoms associated with statistically significant improvement were regurgitation, crying, and arching.

Comment: These children did not have a gold-standard diagnosis of GER disease based on pH-probe or other tests. However, many infants are treated empirically, so a study of patients with symptoms suggesting GER is clinically relevant. Although a control group might have shown similar improvement over time, the authors argue that the decline in GER severity was not explained by the natural progression of symptoms alone, because older infants improved as much as younger infants and the time period studied was short. Because most infants with GER-like symptoms will improve with conservative measures alone, a reasonable strategy is for pediatricians to observe symptomatic infants and to educate their parents about conservative therapies, reserving medications and referrals for the minority of infants who fail to improve over time or who have severe symptoms (respiratory compromise, failure to thrive, or hematemesis) indicating true GER disease.

— Cornelius W. Van Niel, MD