- Oral Aversion: food refusal
- Oromotor Dysfunction: difficulty with the suck and swallow mechanism
- Gastrointestinal Dysmotility: nutrition is not tolerated in the gastrointestinal tract
- Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD): regurgitation of stomach contents into the esophagus, with or without pain or vomiting
- Lifestyle Changes: These include shorter and more frequent feeds, avoidance of tobacco smoke, upright positioning during and after feeding for at least 20 minutes, and keeping the infant calm after the feeding. Prone positioning while awake and being actively monitored may improve symptoms in some infants. Inclined supine positioning for sleep (head elevated above feet) has not been demonstrated to be beneficial.
- Thickening: Many thickening agents have been used including rice cereal, commercially available thickeners and “anti-reflux” formulas. Rice cereal has been used up to a maximum amount of 1 tablespoon of rice cereal per 1 oz. of expressed breastmilk or infant formula. The use of cereals or other thickeners pose certain risks to infants including an unnecessary increase in caloric intake. In particular, thickened feeds increase the preterm infant’s risk of necrotizing enterocolitis. Additionally, recent reports have raised concern for the arsenic content in rice thus raising concern for the use of infant rice cereal which has traditionally been the cereal trialed as a thickener. Commercially available thickeners also may pose some risk particularly for preterm infants who were recently in the NICU. [FDA: 2014] Therefore, thickeners of any type should only be used in consultation with a physician.
- Dairy-free diet: As some infants have difficulty digesting milk (and soy) proteins, a 2-4 week trial of a dairy-free diet may be beneficial. For breastfed infants, the mother eliminates dairy and egg from her diet. For formula-fed infants, a hypoallergenic formula may be trialed. These formulas typically avoid use of milk or soy proteins and may be extensively hydrolyzed casein protein or amino-acid based formulations. Most infants outgrow dietary protein intolerance by 1 year of age.
- Medications: Proton pump inhibitors such as omeprazole and lansoprazole are considered more effective than other antacids and histamine 2 receptor antagonists such as ranitidine. However they are more costly and may require insurance preauthorization. Use of medications should be done sparingly and in consultation with the primary care clinician, as they pose risks to the infant. Babies using anti-reflux medications should not be continued on these medications indefinitely. Double coverage with an H2 blocker and proton pump inhibitor is typically not needed. There is insufficient evidence that the benefits outweigh the substantial risks associated with the use of prokinetic agents in infants with GERD, including metoclopramide, erythromycin, bethanechol, and baclofen.
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|Authors:||Jennifer Goldman-Luthy, MD, MRP, FAAP - 12/2014
Sarah Winter, MD - 11/2014
Sherrily Brown, FNP - 9/2014
|Reviewing Author:||Mary Ann Nelin, MD - 12/2014|
|Content Last Updated:||12/2014|
FDA Expands Caution About SimplyThick.
FDA; (2014) http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm256250.htm. Accessed on 8/15/2014.
FDA warns that SimplyThick may increase the risk of necrotizing enterocolitis (NEC).
Lam HS, Ng PC.
Use of prokinetics in the preterm infant.
Curr Opin Pediatr. 2011;23(2):156-60. PubMed abstract
Yee WH, Soraisham AS, Shah VS, Aziz K, Yoon W, Lee SK.
Incidence and timing of presentation of necrotizing enterocolitis in preterm infants.
Pediatrics. 2012;129(2):e298-304. PubMed abstract / Full Text