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Am Fam Physician. 2005;71(11):2091

Clinical Question

Do thickened feeds, elevating the head of the crib, and metoclopramide therapy improve the symptoms of gastroesophageal reflux (GER) in normally developing children younger than two years?

Evidence-Based Answer

Thickened feeds and metoclopramide reduce symptoms of GER in normally developing infants. However, elevating the head of the crib appears to have no effect.

Practice Pointers

Although virtually all infants regurgitate, or “spit up,” about 3 percent of normally developing infants have clinically significant GER. If an infant has poor weight gain, excessive crying, irritability, disturbed sleep, respiratory problems, or signs of obstruction, diagnostic testing or referral is indicated. Referral also is indicated for patients whose symptoms persist beyond 24 months of age. Common first-line treatments are reassuring parents, elevating the head of the baby’s crib, trying a hypoallergenic formula, and thickening feeds with rice cereal or a rice- or carob-based thickener. Medication sometimes is used for refractory or complicated cases.1

To determine whether common practice is supported by the literature, Craig and colleagues systematically reviewed randomized trials involving thickened feeds, positioning, or metoclopramide to reduce the symptoms of reflux in children younger than two years with no apparent developmental delay. They found 20 trials with a total of 771 infants; eight trials studied thickened feeds, five positioning, and seven metoclopramide. However, not all studies in each group could be compared because of the differences in measured outcomes. Standardized mean differences (SMDs) and weighted mean differences (WMDs) were reported; more negative numbers indicate a greater reduction.

Neither elevating the head of the bed nor putting the patient in prone position (five studies) was found to be effective in reducing reflux. However, thickening feeds (two studies with 48 patients in total) significantly reduced the regurgitation severity score (SMD: −0.94) and frequency of vomiting (SMD:−0.91). Thickened feeds were not found to reduce the reflux index (WMD: 0.48), and may increase the chances of cough and diarrhea. Metoclopramide (two studies totalling 101 patients) significantly reduced daily symptoms (SMD: –0.73), and the reflux index (WMD: –2.80). Side effects such as irritability or drowsiness may occur, although results were heterogeneous. Results of studies that could not be combined generally were similar to those reported above.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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