Gastroesophageal reflux is very common in infants, rarely serious and usually self resolves.
However, some infants with reflux are described as fussy, irritable and inconsolable. These babes’ are often found arching, pulling away, struggling with feeding or flat out refusing to feed. Parents are exhausted, they haven’t had a good night’s sleep in weeeeeks, they have tried every combination of baby holding, they are overwhelmed and looking to you for help.
This is troublesome gastroesophageal reflux.
If you’re a dietitian working with infants, GUARANTEED you will run into infants with reflux along the way. It’s one of the most common issues we come across.
As dietitians we all know that where one strategy might be very effective in one patient, it doesn’t work at all in another. Some infants do well with positioning, some on medication alone, while some require every strategy under the moon and the sun and then some. This leaves us constantly trying to expand our tool belt of possible management strategies, especially when it comes to reflux.
That’s why we wanted to revisit thickening feeds as a possible tool to help manage infant reflux.
What is infant reflux?
NASPGHAN 2018 defines reflux as either:
Gastroesophageal reflux (GER): the passage of gastric contents into the esophagus with or without regurgitation and/or vomiting
Gastroesophageal reflux disease (GERD): when GER leads to troublesome symptoms and/or complications
Common symptoms in infants
Excessive crying, back arching, regurgitation and irritability
GER becomes worrisome when accompanied by:
Poor weight gain, feeding refusal, difficulty swallowing, sleep disturbances and/or respiratory symptoms
NASPGHAN 2018 supports the following strategies to help manage infant reflux
STEP 1: Avoid overfeeding, consider thickening fluids, encourage breastfeeding
STEP 2: In breastfed infants, eliminate cow’s milk in maternal diet or offer protein hydrolysate or amino acid based formula in the formula-fed infant for 2-4 weeks
For more information on this strategy, check out our free webinar: When Reflux Becomes Complicated: Interventions for a Breastfed Infant
STEP 3: Physician referral where they can consider a 4-8 week trial of acid suppression and/or further testing
Are thickeners an effective treatment for infant reflux? What does the science say?
Thickening feeds is thought to prevent symptoms of GER by increasing the “stickiness” of formula in the stomach and preventing retrograde movement of stomach contents into the esophagus.
Cochrane Review 2017: “Thickened feeds generally decrease the number of reflux episodes in full-term formula-fed infants.”
NASGPHAN 2018: “Thickeners were found to reduce visible vomiting and/or regurgitation but their impact on non-regurgitation symptoms is less clear. There is no definitive data showed one thickener better than another.”
Thickeners can be an effective strategy to manage visible regurgitation
Are all thickeners created equal? Which one should you use and when?
There are many different thickeners. We’ll review three categories:
Pre-thickened spit up formulas
What you need to know:
Follows a standardized recipe
Usually contains rice starch that thickens in the stomach with the stomach acid
Does not displace nutrients
Does reduce flow rates of nipples and tubes
At recipe concentrations >or= 27 kcal/oz may become too thick and clog nipples and tubes
Is ineffective when the infant is already taking a proton pump inhibitor (PPI) medication to help manage their reflux
What you need to know:
Affordable and easy to find
Easy to dissolve
No standardized recipe (literature ranges from 1.5-2.5 tsp of infant cereal per oz of formula, different formulas require varying amounts of infant cereal to get the same level thickness)
Can easily become too thick
Does displace nutrients and is high in iron (1 tsp of infant cereal has ~0.7 mg of iron)
Cannot be used with expressed breast milk (EBM) as the natural enzymes degrade the starch
*The American Academy of Pediatrics (AAP) “recommends against the routine use of rice cereal in the bottle to improve infant sleep patterns as it is a choking hazard and may lead to excessive weight gain”.
What you need to know:
Carob bean is safe and indicated in infants <1 year
It can be mixed with both EBM and formula once term infants are >2.7 kg or once preterm infants are at least 42 weeks of gestation and weigh >2.7 kg
Some commercial thickeners are unsafe in infants as they have been linked with increased risk of necrotizing enterocolitis (NEC) and are therefore not indicated for infants <1 year of age
What should you watch out for? Monitor for these red flags!
A reduction in the amount of EBM or formula consumed
Problems with constipation
Problems with coughing or choking during feeds
Probing questions before you start thickening feeds
Is the infant’s reflux troublesome? What other strategies have been tried?
Is the infant term or at least 42 weeks of gestation?
Does the infant weigh at least 2.7 kg?
How is the infant fed?
Is the infant breastfed? Is the infant bottling expressed breast milk or formula?
Which thickening strategy will work best?
A trial of a pre-thickened formula?
Or adding a commercial thickener to expressed breast milk or formula?
Which thickener will be safest for the age of the infant?
If an infant is experiencing troublesome reflux and you believe thickening feeds is a safe option, you can consider a ~2 week trial as tolerated
With any worrisome symptoms, discontinue the trial and move on to other strategies
If well tolerated and is effectively helping to manage symptoms, reassess every few months to see if can be stopped
We’d love to hear from you. Are you routinely thickening feeds for the management of reflux? Or, is it still a strategy of the past?
Charlene and Julie
P.S. If you’d love to know more about infant nutrition, join our waitlist for our flagship course Infant Nutrition Essentials.