An infant with benign reflux who’s thriving requires no investigations and no treatment — the condition is harmless and self-limiting. The child with GERD, though, will require therapy, both non-pharmacologic and with meds. For instance, infants will regurgitate less in the prone position than supine, so a change in positioning may be good. This, of course, conflicts with the advice of putting babies to bed on their back to prevent sudden infant death syndrome (SIDS), so we can’t recommend sleeping on the stomach.
Although an upright position may decrease spit-up, placing an infant in a car seat or seated position may actually increase it. For bottle-fed babies, thickening the formula with rice cereal (15 mL dry per 30 mL formula) can be helpful. Finally, an acid suppressant such as cimetidine (5-15 mg/kg/day divided into 2 doses) may be prescribed for extreme fussiness and pain of esophagitis.
One of the common pitfalls is to presume a milk allergy and advise a change to soy-based formula. Occasionally, infants with that diagnosis may present with emesis, but they’d often have diarrhea and blood in the stool. This is not the case with the majority of infants with GERD, nor is there any benefit to discontinuing breastfeeding. A recent study by S.R. Orenstein and J.D. McGowan (J Pediatr 2008;152[3]: 310-4) showed that conservative measures plus tobacco smoke avoidance resulted in a decrease in symptoms in 78% of infants with GERD, after only 2 weeks.
Richard Haber, MD, FAAP, FRCPC is an associate professor of pediatrics at McGill University and the Director of the Pediatric Consultation Centre at the Montreal Children’s Hospital.