A 4-month-old boy is brought to the office by his mother due to concerns about feeding. The patient has been drinking formula since birth and drinks 3-4 oz every 2-3 hours. His mother says, "Within 15 minutes of each feed, my son throws up a yellowish liquid that looks like partially digested formula. The spit-up dribbles on his and my clothes, and I have had to change our shirts several times a day for the past few months." The patient has 2 soft, yellow stools each day. He has no coughing or choking with feeds. He was born at 39 weeks to a gravida 1 para 1 woman and lives with both parents. Review of his growth chart shows a birth weight at the 47th percentile, with today's weight at the 44th percentile. Physical examination reveals a well-appearing, well-nourished infant lying in his mother's arms. The anterior fontanelle is soft and flat, and the abdomen is soft, nontender, and nondistended. The mucous membranes are moist and skin turgor is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 4-month-old boy is brought to the office by his mother due to concerns about feeding.  The patient has been drinking formula since birth and drinks 3-4 oz every 2-3 hours.  His mother says, "Within 15 minutes of each feed, my son throws up a yellowish liquid that looks like partially digested formula.  The spit-up dribbles on his and my clothes, and I have had to change our shirts several times a day for the past few months."  The patient has 2 soft, yellow stools each day.  He has no coughing or choking with feeds.  He was born at 39 weeks to a gravida 1 para 1 woman and lives with both parents.  Review of his growth chart shows a birth weight at the 47th percentile, with today's weight at the 44th percentile.  Physical examination reveals a well-appearing, well-nourished infant lying in his mother's arms.  The anterior fontanelle is soft and flat, and the abdomen is soft, nontender, and nondistended.  The mucous membranes are moist and skin turgor is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf37_8555_8f63_b32d2525cfe7_MD0005_00 Gastroesophageal reflux (GER), or spit-up, is common and normal in the majority of infants as they have a relatively relaxed lower esophageal sphincter. The esophagus is also shorter and the stomach is smaller compared with that of older children. Breastmilk and formula are easily regurgitated up the esophagus and out of the mouth; however, the episodes do not cause injury, weight loss, or other complications. Infants are commonly described as "happy spitters," and GER is colloquially referred to as "a laundry problem, not a medical problem." Gastroesophageal reflux GER is distinguished clinically from gastroesophageal reflux disease (GERD), which causes complications such as weight loss, feeding refusal, respiratory complications (eg, aspiration), and significant pain with back-arching and irritability during feeds. This patient has appropriate weight gain and no pain with feeds, which is consistent with physiologic GER. Initial management includes reassurance and lifestyle modifications. Upright positioning after feeds, burping during feeds, and frequent, small-volume feeds are first-line interventions. GER is typically more frequent during the first few months of life, with peak symptoms around age 4 months; it is expected to self-resolve by age 12-18 months. (Choice A) Abdominal ultrasound diagnoses pyloric stenosis, which typically presents at age 3-6 weeks with projectile vomiting with feeds. Pyloric stenosis is rare after age 3 months and unlikely in this patient with nonforceful regurgitation. (Choices B and D) Nissen fundoplication and endoscopy are reserved for GERD that does not respond to medical management. (Choice C) Pharmacologic therapy with H2 receptor antagonists (eg, ranitidine) is indicated only in infants with GERD who have poor weight gain and marked irritability despite lifestyle modifications and a trial of a diet free of cow's milk. Educational objective: Gastroesophageal reflux is a common physiologic phenomenon in infants and is characterized by spit-up with appropriate weight gain and no pain with feeds. First-line management includes reassurance and lifestyle modifications (eg, upright positioning after feeds). References: Gastroesophageal reflux: management guidance for the pediatrician. (http://www.ncbi.nlm.nih.gov/pubmed/23629618) Gastroesophageal reflux disease. (http://www.ncbi.nlm.nih.gov/pubmed/28502434)

A 4-Month-Old Boy Is Brought to the Office by His