Chapter 11

• Gastroesophageal reflux (GER) is a very common problem in young infants.
• Pathologic GER is associated with multiple medical problems.
• Most patients with GER respond to conservative treatment.
• Cow's milk protein allergy (CMPA) affects a significant percentage of infants. Many of these patients are also intolerant of Soy protein.
• Patients with CMPA should be switched to an extensively hydrolyzed- or amino acid–based formula.

For the human infant, the first year of life, and especially the first 6 months, is a period of explosive growth. Sustaining normal weight gain and development require virtually continuous intake of a large amount of calories. For the first 4 months, this occurs almost exclusively via the intake of liquid, either as breast milk or formula. After 4 months, solid foods are gradually introduced. Problems related to feeding are common, especially in younger infants, many of whom will present to an emergency department (ED) for diagnosis and treatment. This chapter will focus on two feeding problems especially common in younger infants: gastroesophageal reflux and formula intolerance.

Gastroesophageal reflux (GER) occurs when there is retrograde flow of gastric contents into the esophagus. Some degree of GER is so common in infants that it can be considered a normal variant in the first year of life. It is thought to be due to immaturity of lower esophageal sphincter function that results in transient lower esophageal sphincter relaxations (tLSER). Less commonly, GER can be secondary to motility disorders or gastric outlet obstruction. Clinically, gastrointestinal reflux presents as regurgitation or vomiting of breast milk or formula. The vast majority of babies vomit during the first week of life; 60% to 70% suffer from some element GER at age 3 to 4 months.1 Emesis can be forceful, or of the mild variety often referred to as “spitting up.” The emesis usually occurs after feeding; it should never be bilious or bloody. Most cases of gastrointestinal reflux are physiologic, which implies that there is no associated underlying pathology, growth and development are normal, and there are no resultant medical complications. Physiologic reflux usually resolves by approximately 1 year of age. Pathologic GER is associated with multiple complications including poor weight gain or failure to thrive, esophagitis, and respiratory complications, including reactive airway disease and recurrent pneumonia, thought to be secondary to recurrent aspiration. In patients with severe GER, these complications can coexist. There may be a relationship between GER and acute life-threatening events. Risk factors for GER include prematurity and underlying neurologic disease. CMPA may also be implicated as a cause of GER.1,2

The history of the infant suspected of having GER includes determining the amount and frequency of feeding, especially in formula-fed infants, in whom overfeeding is common as well as noting whether the formula is cow's milk or soy based. Stooling pattern is evaluated, especially for the presence of bloody diarrhea that could indicate a formula allergy. Infants with pathologic or symptomatic GER often have ...

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