FPIN's Help Desk Answers

Thickened Feedings for Infants with Gastroesophageal Reflux


Am Fam Physician. 2019 Oct 1;100(7):437.

Clinical Question

Does the use of thickened feedings lead to better outcomes in infants with gastroesophageal reflux?

Evidence-Based Answer

Bottle-fed infants with gastroesophageal reflux should be given thickened formula feedings. (Strength of Recommendation: A, based on consistent meta-analyses of randomized controlled trials [RCTs].) Thickened formula feedings moderately decrease occurrences of regurgitation and parent-reported symptoms, and they improve weight gain compared with nonthickened formula feedings.

Evidence Summary

A 2017 meta-analysis included eight RCTs comparing thickened feedings vs. usual formula in bottle-fed term infants up to six months of age with gastroesophageal reflux (N = 637).1 Feed thickeners varied (carob bean gum, cornstarch, or rice cereals), and study duration ranged from one to eight weeks. At the end of therapy, there were fewer episodes of regurgitation per day in the thickened feedings group (eight RCTs; n = 637; weighted mean difference [WMD] = −1.97; 95% CI, −2.43 to −1.61), and infants receiving thickened feedings were more likely to be asymptomatic from regurgitation (eight RCTs; n = 637; relative risk [RR] = 2.5; 95% CI, 1.38 to 4.51). No major adverse effects were reported in term infants receiving thickened feedings. The RCTs included in the systematic review were limited by unclear risk of allocation bias and potential lack of blinding of parents who may have noted the increased viscosity of thickened formula.

A 2008 meta-analysis of 14 RCTs (six of which were double-blinded; N = 877) of healthy infants and children 24 months or younger compared thickened feedings vs. placebo or usual formula for gastroesophageal reflux.2 Control groups received nonthickened formula, and interventions lasted one to eight weeks. Primary outcomes were changes in reflux symptoms (e.g., regurgitation, vomiting, crying, gagging) and adverse effects as reported by parents, guardians, or physicians. Six of the RCTs were also included in the 2017 meta-analysis discussed above; however, this meta-analysis also reported

Address correspondence to Laura Morris, MD, MSPH, FAAFP, at morrislau@health.missouri.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Copyright © Family Physicians Inquiries Network. Used with permission.


1. Kwok TC, et al. Feed thickener for infants up to six months of age with gastro-oesophageal reflux. Cochrane Database Syst Rev. 2017;(12):CD003211.

2. Horvath A, et al. The effect of thickened-feed interventions on gastroesophageal reflux in infants [published correction appears in Pediatrics. 2009;123(4):1254]. Pediatrics. 2008;122(6):e1268–e1277.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN's Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.



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