Thickened Infant Formula Does What It Has to Do: Decrease Regurgitation

To the Editor.—Horvath et al published a systematic review on the effect of thickened-feed interventions on gastroesophageal reflux (GER).1 The authors concluded that their meta-analysis showed that thickened food is only moderately effective in treating GER in healthy infants.However, GER is healthy infants does not need treatment.2 GER is a normal physiologic process that occurs several times per day in healthy infants, children, and adults. Approximately 50% of normal 3- to 4-month-old infants regurgitate at least once per day,3,4 and up to 20% of caregivers in the United States seek medical help for this normal behavior.3Thickening agents such as rice cereal added to formula do not decrease esophageal acid exposure but do decrease the frequency of overt regurgitation.2 A combined impedance-pH-metry study showed a decreased reflux esophageal height with thickened formula, as well as a decrease in the overt frequency of regurgitation, but no change in the frequency of reflux episodes.5Whether there is an effect of thickened formula on (acid) GER is not relevant, because physiologic (acid) reflux does not need treatment. Horvath et al concluded that there are no data to suggest that “one particular thickening agent is more effective than another.”1 However, some thickening agents seem to have an influence on acid reflux. The meta-analysis suggested a moderate increase of the reflux index (percent time of acid reflux) with rice, an intermediate decrease with carob bean gum, and a clear significant beneficial effect of cornstarch.1 Moreover, not all randomized trials with cornstarch have been included. A study by Ramirez-Mayans et al6 also showed a decrease of the reflux index with cornstarch.Horvath et al demonstrated in their meta-analysis a significant increase in the number of infants without regurgitation and in the number of episodes of regurgitation and vomiting per day.1 Frequent regurgitation is a main reason for parents to seek medical help.3Most of the studies suggested that thickened infant formula does what it is intended to do: decrease regurgitation and strengthen the effect of “parental reassurance,” which is what has to be considered the cornerstone of the management of infant regurgitation. Any additional effect on GER may be considered as an additional benefit but is, in fact, not relevant. Because of the data available in the literature, recommendation should be to use only these thickened agents and commercial thickened formulas that have been clinically evaluated.In infants presenting with frequent regurgitation as a cause of parental anxiousness, management should be based on parental education, anticipatory guidance, and modification of feeding frequency and volume if necessary.2 Overfeeding exacerbates recurrent regurgitation and should be avoided. In some infants with persistent regurgitation, a thickened or commercial antiregurgitation formula may help control the frequency of regurgitation.2 There is no evidence that antisecretory or promotility agents improve physiologic infant regurgitation.