title: A systematic review of nonpharmacological and nonsurgical therapies for gastroesophageal reflux in infants.
abstract: BACKGROUND
  Nonpharmacological and nonsurgical measures are often recommended for gastroesophageal reflux disease (GERD) in infants, despite ambiguous supporting evidence.
  
  
  OBJECTIVE
  To conduct a systematic review of rigorously evaluated nonpharmacological and nonsurgical therapies for GERD in infants.
  
  
  METHODS
  We searched online bibliographic databases, including MEDLINE, EMBASE, the Cochrane Collaboration and Clinical Trials Database, and alternative medicine databases for the terms gastroesophageal reflux and infants. We selected randomized controlled trials of nonpharmacological and nonsurgical GERD therapies in otherwise healthy infants. Data were extracted from the selected articles regarding reflux, emetic episodes and intraesophageal pH.
  
  
  RESULTS
  We identified 43 relevant studies, of which 10 met the selection criteria. These studies examined positioning, pacifier use, and feeding changes. Positioning at a 60 degree elevation in an infant seat was found to increase reflux compared with the prone position. No significant difference was shown between the flat and head-elevated prone positions. The impact of pacifier use on reflux frequency was equivocal and dependent on infant position. The protein content of formula was not found to affect reflux. Although no study demonstrated a significant reflux-reducing benefit of thickened infant foods compared with placebo, 1 study detected a significant benefit of formula thickened with carob bean gum compared with rice flour (pH<4 for 5% vs 8% of time). Another study showed that if supplementing with dextrose 5% water or dextrose 10% water, the lower-osmolality fluid was associated with less reflux.
  
  
  CONCLUSIONS
  Many conservative measures commonly used to treat GERD in infants have no proven efficacy. Although thickened formulas do not appear to reduce measurable reflux, they may reduce vomiting. Further studies with clinical outcomes are needed to answer questions about efficacy definitively.
authors.affiliation: Robert Wood Johnson Clinical Scholars Program, University of Washington, H-220 Health Sciences Center, Box 357183, Seattle, WA 98195-7183, USA. acarro@u.washington.edu
authors.forename: Aaron E
authors.initials: AE
authors.lastname: Carroll
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Garrison
authors.forename: Dimitri A
authors.initials: DA
authors.lastname: Christakis
mesh_terms: D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D007223:Infant; D007225:Infant Food; D007231:Infant, Newborn; D015995:Prevalence; D016684:Prone Position; D016032:Randomized Controlled Trials as Topic