Pathophysiology of Gastroesophageal Reflux Disease in Infants and Nonpharmacologic Strategies for Symptom Management

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• Reviews of nonpharmacologic management   

• Clinicians, in the past, have thought of GER in infants as a disease process, associated with an immature lower esophageal sphincter (LES) 

• “The LES is the muscle that separates the lower end of the esophagus from the stomach; it briefly relaxes and opens after swallowing to allow the food bolus to move from the esophagus into the stomach, and then closes to keep the acidic stomach contents from moving back up into the esophagus (El-Mahdy et al., 2017).” 

• When infant is younger that 6 months old, “GER results from a combination of factors related to the natural course of infant development and circumstances that result in increased frequency and/or prolonged duration of opening of the LES” 

• Infants typically lack the gross motor skills to maintain their bodies in an upright position (El-Mahdy et al., 2017). When lying in a horizontal position, the anatomic positioning of the LES combined with the liquid diet allows for gastric contents to readily move up into the esophagus when the LES opens. When there are factors that contribute to increased frequency and/or prolonged duration of opening of the LES, GER results. 

• Pharmacologic management of GERD focuses primarily on reducing the acidity of the refluxate. 

• not been found effective because they target only the effect of stomach acid on the esophageal tissue. Improves and prevents other problems  

• changing the acidity of the refluxate may improve esophagitis and prevent esophageal strictures 

• but doesn’t diminish the amount of refluxes. 

• overfilling of the stomach may cause increased pressure on the LES, resulting in GER 

 

 

Safety considerations when managing gastro-esophageal reflux disease in infants.

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• Non-pharmacological treatment is often effective and safe. (“Safety Considerations When Managing Gastro-Esophageal Reflux Disease in Infants,” 2021) 

• Managing reflux with Prokinetics, [Drug class] has a risk of adverse effects that outweighs the benefit.  (“Safety Considerations When Managing Gastro-Esophageal Reflux Disease in Infants,” 2021)   

• Regurgitation in infants is resolved within 12 –18 months. (“Safety Considerations When Managing Gastro-Esophageal Reflux Disease in Infants,” 2021)     

• Non-pharmacological treatments can be: positioning, adapted feeding volume, frequency, composition 

• Left lateral positioning showed a greater reduction in reflux episodes compared to head elevation, but  

 

Gastroesophageal Reflux Disease in Neonates and Infants.

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• Gastroesophageal reflux (GER) is very common in infants. 70-85% of them experience regurgitation in the first 2 months. In 95% of cases, this is completely resolve around the age of 1, without any medical intervention. 

• Pharmacologic treatment is not recommended, but some non-pharmacologic approaches can help mitigate symptoms 

• Some options for treatment are: 

• Parental reassurance 

• Most cases of GER are mostly harmless, so educating and reassuring the parents is important. 

• Thickening of formula 

• Decreases the frequency of regurgitation and vomiting 

• Increases weight gain 

• Dietary change 

• Some babies are allergic to cow’s milk protein, which symptoms mimic GER 

• Positioning 

• Keeping the baby in a prone position limits reflux 

• Babies should generally sleep in a supine position, even if they have reflux 

• Sleeping on left-side could reduce reflux in contrast to right lateral position