A 3-month-old boy presents to the pediatrician with his mother for a well-child visit. The patient drinks 4 ounces of cow’s milk formula every 3 hours. He usually stools 1 time per day and urinates up to 6 times per day. He regurgitates a moderate amount of formula through his nose and mouth after most feeds. He does not seem interested in additional feeding after these episodes of regurgitation and he has become progressively more irritable around meal times. The patient is starting to refuse some feeds. His mother denies seeing blood or streaks of red in his stool and she denies any family history of food allergies or dermatological problems. The patient’s weight was in the 62nd percentile 4 weeks ago and he is now in the 48th percentile. His height and head circumference have followed similar trends. His temperature is 98.2°F (36.8°C), blood pressure is 72/47 mmHg, pulse is 125/min, and respirations are 27/min. On physical exam, the patient smiles reciprocally and can lift his head and chest when in the prone position. His abdomen is soft, non-tender, and non-distended. Which of the following is the most appropriate next step in management?
Provide reassurance
Counsel on positioning and thickening feeds
Obtain abdominal ultrasound
Initiate proton pump inhibitor
Counsel on positioning and thickening feeds
This patient presents with frequent regurgitation after feeding, worsening irritability, feeding aversion, and poor weight gain, which is concerning for gastroesophageal reflux disease (GERD). The most appropriate next step in management is counseling on proper positioning and thickening feeds.

Infants with GERD may present with regurgitation or vomiting after feeding, significant irritability, feeding aversion, and poor weight gain or failure to thrive. Symptoms can usually be managed with lifestyle changes including more frequent, thicker, and lower volume feeds and positioning the patient upright during and after feeding. If symptoms continue, patients should undergo a trial of a dairy-free diet to address possible underlying food protein intolerance. Pharmacotherapy with proton pump inhibitors (PPI) is appropriate for patients with persistent symptoms despite these changes, although PPIs can increase the risk of pneumonia and infection with C. difficile.

Chabra and Peeples review the evidence regarding the treatment of neonatal GERD. They discuss how alterations in the infant's environment and feeding pattern are effective in most cases. They recommend proton pump inhibitors if conservative treatments are not effective.

Incorrect Answers:
Answer B: Initiating medical therapy with a proton pump inhibitor is appropriate for patients who have already failed lifestyle changes, including positioning therapy, adjusting feeding patterns, and eliminating cow’s milk and soy from the diet.

Answer C: Obtaining an abdominal ultrasound would help diagnose pyloric stenosis. Patients with pyloric stenosis typically present at a younger age (between 3 and 6 weeks of life) with non-bilious, projectile vomiting and a palpable “olive-shaped” mass in the epigastrium. Treatment is with a pyloromyotomy.

Answer D: Providing reassurance would not be appropriate due to this patient’s poor weight gain. Although most cases of gastroesophageal reflux are uncomplicated and self-resolve by 1 year of age, this patient’s symptoms should be addressed to ensure he is meeting his nutritional requirements.

Answer E: Switching to a hydrolyzed formula to eliminate cow’s milk and soy protein from the patient’s diet would be appropriate if the patient’s symptoms did not improve with changing position and thickening feeds.

Bullet Summary:
The most appropriate initial step in managing gastroesophageal reflux disease in infants is counseling on proper positioning and thickening feeds.