A 3-month-old boy is brought to the office due to recurrent episodes of spitting up. He was breastfed for the first 2 months of life without any concerns. According to the mother, over the past 3 weeks, the patient has been vomiting within minutes after every feed. The emesis appears to be partially digested breast milk. However, he is eager to eat every 3 hours and has no color change, respiratory distress, or irritability with feedings. The patient was born at term following an uncomplicated pregnancy and is taking no medications. Vital signs are normal. On examination, lung and heart sounds are normal, and the abdomen is soft and nontender, without hepatosplenomegaly. The growth chart is shown in the image below: Which of the following is the best next step in management of this patient?

Question

A 3-month-old boy is brought to the office due to recurrent episodes of spitting up.  He was breastfed for the first 2 months of life without any concerns.  According to the mother, over the past 3 weeks, the patient has been vomiting within minutes after every feed.  The emesis appears to be partially digested breast milk.  However, he is eager to eat every 3 hours and has no color change, respiratory distress, or irritability with feedings.  The patient was born at term following an uncomplicated pregnancy and is taking no medications.  Vital signs are normal.  On examination, lung and heart sounds are normal, and the abdomen is soft and nontender, without hepatosplenomegaly.  The growth chart is shown in the image below:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d676_0b72_bc81_b7320e09ba0b_MD0003_00 This patient's normal growth chart indicates that his symptoms are due to gastroesophageal reflux (GER), a benign, physiologic process of infancy. GER is caused by an immature lower esophageal sphincter, which allows the retrograde flow of gastric contents into the esophagus. The majority of infants experience GER; however, those exposed to tobacco smoke, which reduces esophageal sphincter pressure, are at increased risk. GER generally presents in the first 6 months of life (peak symptoms at age 4 months) with spit-up or vomiting of partially digested breast milk or formula after feeding. In contrast to pathologic reflux, physiologic GER does not cause discomfort while spitting up, and infants continue to feed eagerly, with normal weight gain. These infants are often called "happy spitters." Diagnosis is clinical based on characteristic features and a normal examination. Management includes education about preventive measures (eg, upright positioning after feeds), as well as reassurance that symptoms typically self-resolve by age 12-18 months. Breastfeeding should be encouraged because it may have a protective effect against GER. However, because breast milk has inadequate vitamin D with poor bioavailability, cholecalciferol (vitamin D) supplementation should be prescribed in all breastfed infants regardless of GER. (Choices A, D, and E) Signs of pathologic GER include irritability, poor feeding, and/or weight loss. Initial management in bottle-fed infants may include thickening feeds or switching to an extensively hydrolyzed formula. Breastfed infants may benefit from elimination of cow's milk and soy protein from the mother's diet. Soy formula is not recommended because many infants with milk protein intolerance are also sensitive to soy. For problematic reflux that persists despite nonpharmacologic measures, a trial of acid-suppression therapy (eg, proton pump inhibitor) may be warranted. This infant is a "happy spitter" with normal growth, so no treatment is required. (Choice C) Higher-frequency, lower-volume (not lower-frequency, higher-volume) feeds are recommended for patients with spit-up to reduce overfeeding and gastric distension that could contribute to GER. Educational objective: Physiologic gastroesophageal reflux (ie, spit-up) is common in the first 6 months of life and characterized by infants who are "happy spitters" with normal weight gain and examination. Management is reassurance, and continued breastfeeding with cholecalciferol (vitamin D) supplementation is encouraged. References: Gastroesophageal reflux: management guidance for the pediatrician. (http://www.ncbi.nlm.nih.gov/pubmed/23629618) Gastroesophageal reflux disease in neonates and infants: when and how to treat. (http://www.ncbi.nlm.nih.gov/pubmed/23322552)

A 3-Month-Old Boy Is Brought to the Office Due to Recurrent