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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0000000000000401
Letter to the Editor

Revisiting Infant Gastroesophageal Reflux Disease Guidelines: Considering Obesity

Gheller, Brandon*; King-Moore, Cynthia; Otley, Anthony; Van Limbergen, Johan

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*Applied Human Nutrition, Mount Saint Vincent University

Division of Gastroenterology & Nutrition, IWK Health Centre

Department of Pediatrics, Division of Gastroenterology & Nutrition, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada

To the Editor: Recently, a physician contacted our dietitians about thickening 1 oz of infant formula with 1 tbsp rice cereal to aid infants’ gastroesophageal reflux disease (GERD). This method of thickening formula appears in the joint publication, “Parent's Take Home Guide to GERD” by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Children's Digestive Health and Nutrition Foundation, and American Academy of Pediatrics (1). Adding 1 tbsp cereal to 1 oz formula increases caloric density to an estimated 1.1 kcal/mL (2). Additionally, there is a change from an appropriate macronutrient distribution to on that is incongruent with the acceptable macronutrient distribution ranges (3) (fat 48%–24%, carbohydrate 43.5%–68%, protein 8%–8%). Feeding skewed amounts of macronutrients to infants is associated with obesity in childhood; although the effect has been best elucidated with protein, the effects of drastic changes in fat and carbohydrate are unknown (4). Concentrated infant formulas at different ages can result in increased caloric intake and weight gain (5–7). Furthermore, there is no evidence that cereal-thickened formula is superior to noncaloric means in reducing GERD-associated symptoms (8). No clinical trials have evaluated the thickening method endorsed in these publications, and NASPGHAN/ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) guidelines raise similar concerns about changes in caloric density and obesity associated with this practice (2). Considering the association between early infant feeding changes and obesity later in life (9), our opinion is that a reevaluation of the risks of thickening 1 oz of infant formula with 1 tbsp rice cereal be revisited and professional and lay material be changed accordingly.

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REFERENCES

1. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Children's Digestive Health and Nutrition Foundation, American Academy of Pediatrics. Parent's take home guide to GERD (gastroesophageal reflux disease). http://cdhnfsite.wms.cdgsolutions.com/wmspage.cfm?parm1=43. Published May 11, 2003. Accessed November 27, 2013.

2. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gatroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498–547.

3. Institute of MedicineDietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (Macronutrients). Washington, DC:The National Academies Press; 2005.

4. Koletzko B, von Kries R, Closa R, et al. Can infant feeding choice modulate later obesity risk? Am J Clin Nutr 2009; 89:1502–1508.

5. Fomon SJ, Filer LJ, Thomas LN, et al. Influence of formula concentration on caloric intake and growth of normal infants. Acta Paediatr Scand 1975; 64:172–181.

6. Fomon SJ, Filer LJ, Thomas LN, et al. Relationship between formula concentration and rate of growth of normal infants. J Nutr 1969; 98:241–254.

7. Chao HC, Vandenplas Y. Effect of cereal-thickened formula and upright positioning on regurgitation, gastric emptying, and weight gain in infants with regurgitation. Nutrition 2007; 23:23–28.

8. Horvath A, Dziechciarz P, Szajewska H. The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized controlled trials. Pediatrics 2008; 122:e1268–e1277.

9. Koletzko B, Beyer J, Brands B. Early influences of nutrition on postnatal growth. Nestle Nutr Inst Workshop Ser 2013; 71:11–27.

© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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