206 Zevit ShamirFurthermore, since a certain degree of ref lux is
present in normal individuals, symptom associa-
tions are often difficult to demonstrate. In addi-
tion there is a poor correlation between acid ex-
posure and endoscopic findings or symptoms.
pH multichannel intraluminal impedance, a rel-
atively new methodology involving a traditional
pH monitor with several impedance probes lo-
cated throughout the esophagus, is able to over-
come some of these obstacles [8]. This technology
permits direct measurement of bolus transit in
the esophagus both temporally and geographi-
cally. Better symptom association calculations
may be generated. Unfortunately, pediatric
norms are still unavailable, and its high cost lim-
its its use in many regions. Radionucleotide scans
are now rarely used for the diagnosis of GER.
Finally, extensively hydrolyzed or amino acid-
based formulas may be used for infants with
GERD to eliminate the possibility of food allergy
(see section Treatment below).
T r e a t m e n t
In most cases of GER or uncomplicated GERD in
an infant, treatment involves educating the par-
ents as to the generally benign nature of the con-
dition and its natural history in this age group,
stressing that GER is not a disease but rather a
common transient state which in most cases re-
solves toward the end of the first year of life [1].
Coupled with continued follow-up and a trusting
relationship with the pediatrician, further inter-
ventions are usually found to be unnecessary.
While prone positioning of infants has been
found to decrease regurgitations, this is no longer
recommended – except while the infant is awake
and observed by a caregiver – because of the in-
creased risk of sudden infant death in this posi-
tion [1].
However, in some infants, the irritability asso-
ciated with GERD leads to decreased feeding vol-
umes or to large fractions of the ingested food be-
ing regurgitated, with consequent poor weight
gain, aspiration of ref luxed content or indolent
nutrient deficiency (e.g. iron). In these cases and
whenever significant GERD is suspected in chil-
dren, cow’s milk protein allergy should be consid-
ered, because such allergy may present identically
to GERD [9]. A time-limited trial of dietary exclu-
sion of milk products from the maternal diet for
breastfeeding infants, and use of extensively hy-
drolyzed or amino acid-based formulas with oth-
ers, may be at tempted. If no response is seen w it h-
in 2–4 weeks, the infant may return to the previ-
ous diet. If milk allergy is found in a breastfed
infant and the mother continues a milk-restricted
diet, the need for calcium supplementation of the
mother’s diet should be assessed. If dietary re-
striction and rescheduling of feeds fail, other in-
terventions such as thickening of formulas may be
attempted. Thickening of formulas can be per-
formed by caretakers by addition of thickeners
such as corn, rice or potato starch to the water in
which the formulas are to be prepared. Adding
starch changes the nutritional composition of the
feeds and increases carbohydrate calories. Alter-
natives are addition of locust bean gum (from the
carob tree) or guar gum. Additionally, factory-
made antiregurgitation formulas based on either
rice or locust bean gum are available in a nutri-
tionally balanced format. Each has its advantages
and disadvantages, which are beyond the scope of
t h i s c hapter. It mu s t b e note d t hat t he s e a nt i re g u r-
gitation formulas do not cure GER or GERD but
rather decrease the number of regurgitations and
the height of the regurgitant column and may be
nutritionally disadvantaged [10].
When these interventions fail, and GERD has
been diagnosed, medical treatment may be justi-
fied. This may include histamine 2 receptor
blockers, such as ranitidine, or PPI. Currently,
only histamine 2 receptor blockers are approved
for infants under 1 year of age. If used at appro-
pr iate doses , t hey produce a n ef fec t ive acid block-
ade; however, tachyphylaxis may become a prob-
lem after a few weeks use. PPI are considered theKoletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 203–208
DOI: 10.1159/000360341