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First Line Interventions to Manage Infant Reflux

With as many as 40% of infants experiencing regurgitation by 3 to 4 months of age (AAFP 2015), it’s no wonder Dietitians get asked when does crying, fussiness and arching become problematic and what can we do about it?

We get asked a lot of questions about reflux management. Do I have to do anything different in preterm babies? How long do I have to try an intervention before moving on the next one? But the one we get asked most often is:

How can we reduce use of acid suppression medication in infants with reflux? What are some effective, non-invasive, yet evidenced-based strategies we can recommend as dietitians?

We have you covered. But first, let’s review the definitions and prevalence before diving into the evidence around first-line infant reflux management interventions.

GER (Gastroesophageal Reflux) is the passage of gastric contents into the esophagus with or without regurgitation and/or vomiting
GERD (Gastroesophageal Reflux Disease) is when GER leads to troublesome symptoms that affect daily functioning and/or complications
  • GER occurs daily in 50% of infants <3 months and daily in 30% of infants <6 months (Dhillon 2004 and Salvatore 2017)
  • Incidence peaks at four months of age (AAP 2014)
  • Affects 22% of infants born <34 weeks of gestation (Dhillon 2004)

The degree of concern of parents is often the factor driving the need for a diagnosis and to initiate the trials of management interventions

What does the evidence tell us?

Interventions for the Management of Infant Reflux:

1) Provide reassurance

Management should always start with parental support.

2) Encourage breastfeeding

Troublesome regurgitation and GERD are (almost) never a good reason to stop breastfeeding. A diet of exclusively human milk is associated with fewer symptoms of GER and rates of GERD are reportedly lower in breastfed infants compared with formula-fed infants.

3) Avoid overfeeding

The is no evidence to suggest that reduced feeding volume or more frequent feedings are effective in the management of GERD – however it is a consensus that overfeeding is a risk factor.

4) Positioning

Left lateral position results in a reduction in the total number of reflux and vomiting episodes. Keeping infants in an upright (40 degree incline) or prone position may also be effective, although only when awake and under supervision as to avoid the risk of SIDS (sudden infant death syndrome).

5) Thickening

Thickeners can be an effective strategy to manage visible regurgitation – make sure you review which thickener is safe for your patient.



Still uncomfortable with managing infant reflux? Not sure where to start? Curious as to the second- and third-line interventions? What about when all lines of interventions are still insufficient to manage symptoms?

Refer to our Infant GI Series 2023: Navigating Constipation, Reflux, FPIAP & FPIES webinar for all three lines of interventions and a full section on what to consider when everything else fails. Julie shares her clinical experience of what the books and journals don’t talk about.

What are we up to right now at Nutrition Masterclass:

👉 Our yearly deals are just around the corner!

Expect sitewide discounts starting November 20, 2023 on all our online continuing education credits!

If you want to improve your knowledge and confidence around pediatric nutrition, you’ll want to check your inbox next week for more details on how to register for your wish list courses at the lowest prices.

👉 We have a new free webinar coming out in December! Stay tuned!

We heard you loud and clear. You want to know more about how to best manage infants who are being raised on a plant-based diet. Our special guest speaker will cover all your questions.


Mark your calendar! If you want to learn more about the management of infant reflux, our Infant GI Series 2023: Navigating Constipation, Reflux, FPIAP & FPIES will be on sale next week!


Have friends and/or colleagues that would find this newsletter helpful or who would benefit from our yearly sale next week? Forward them this email!


Charlene and Julie

P.S. For more information on thickening feeds for infants, check our blog: Thickening Feeds for Infant Reflux – New Evidence for an Old Strategy.

P.P.S. If you’d love to know more about infant nutrition, get on our waitlist for our next round of our flagship course Infant Nutrition Essentials by clicking HERE.

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