Nonpharmacological and nonsurgical therapies for gastroesophageal reflux

Non-pharmacological (and non-surgical) therapies for reflux do not have any proven efficacy on reflux, although some may decrease the incidence of regurgitation. Lifestyle changes (in adults) are rarely beneficial.96 No significant difference was shown between the flat and head-elevated prone position. Despite gravity, the upright seated position leads to significantly more and larger reflux episodes than the simple prone and 30° elevated prone position, when the infant is awake or asleep.97 This is likely to be due to increased abdominal or intragastric pressure. The supine (lying on the back) and lateral positions (lying on the left or right side) usually result in intermediate pH-metric GER values and do not appear to influence GER.97,98 However, there is now ample evidence that the prone sleeping position is a risk factor in sudden infant death, independent of overheating, adult's smoking or way of feeding. The impact of pacifier ('dummy') use on reflux frequency was equivocal and dependent on infant position. The protein content of formula was not found to affect reflux. Another study suggested that the lower the osmolality, the less acid reflux. Larger food volume and higher osmolality increase the rate of transient LES relaxations and drifts in LES pressure; a reduction of the food volume results in a decrease in the number of regurgitations but no change in acid reflux.99

The data of ten randomized controlled trials of non-pharmacological and non-surgical GERD in healthy infants were recently reviewed.100 Although no study demonstrated a significant reflux-reducing benefit of thickened formula compared to placebo, one study detected a significant benefit of formula thickened with carob bean gum compared with rice flour. Milk-thickening agents include bean gum preparations prepared from St John's bread, a galactomannan, carboxy-methylcellulose, a combination of pectine and cellulose, cereals and starch from rice, potato, corn (maize), etc. There are as many different compositions of anti-regurgitation formulas as there are companies: some are casein-predominant, and others contain protein hydrolysates. Milk thickeners have been reported to reduce regurgitation in infants.97 However, their effects on esophageal acid exposure are inconsistent. Increased coughing has also been demonstrated in infants receiving milk thickeners.97 According to in vitro models testing the effect on one meal, bean gum may be associated with a malabsorption of minerals and micronutrients.101 Studies of various thickening agents, including guar gum, carob bean gum and soybean polysaccharides, indicate the potential for decreased intestinal absorption of carbohydrates, fats, calcium, iron, zinc and copper.102 Abdominal pain, colic and diarrhea may ensue from fermentation of bean gum derivatives in the colon. Carob bean gum induces frequent, loose, gelatinous stools. In some, but not all, animal studies, adding carob bean gum to the diet decreased growth.102 However, growth and nutritional parameters in infants receiving a casein-predominant formula thickened with bean gum were normal.103 Although rare, serious complications such as acute intestinal obstruction in newborns have been reported.97 Milk thickeners are often wrongly considered as 'inexpensive'. Allergic reactions to carob bean gum have been reported in adults exposed to it at their workplaces and in infants after exposure to formula thickened with carob bean gum.102 Nevertheless, in view of their safety and efficacy in decreasing regurgitation, milk thickeners remain a valuable first-line measure in relieving regurgitation in many infants. In contrast, their efficacy in GERD is questionable. Moreover, they are not devoid of side-effects.

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