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    Rice Cereal for Reflux. Does it really work?

    After we posted the article “Should You Introduce Rice Cereal as a First Food?,” we received several questions about rice cereal for reflux.

    To recap the previous article–the general recommendation is not to introduce solids until 6 months, ideally provide breastmilk exclusively for the first 6 months, and introduce regular foods rather rice cereal.

    Rice cereal has been linked to arsenic and associated with non-communicable diseases such as obesity and diabetes. But, what if your child has reflux? Does the benefit outweigh the cost? Gastroesophageal reflux (GER), after all, is one of the most common gastrointestinal (GI) complaints in infancy with an estimated 20-50% of infants who experience symptoms of reflux. Rice cereal is a commonly used home remedy, but does it even work? If we are to continue to use rice cereal to address reflux, despite its potential adverse effects, we ought to at least know if it works.

    As I started to reach more about reflux, I found out that not all reflux is the same and as a result, both diagnosis and treatment is important. One article went so far as to say that appropriate diagnosis and treatment is vital because “ineffective management of a disease that might result in stunting, chronic illness, persistent pain, esophageal scarring and even death.”  (Hegar et al., 2013)

    Wait, what?! As a clinician I may read this objectively, as a mommy I’m a bit mortified. Death by reflux?! My LO had severe reflux and I just blindly followed doctor orders! Had I known what “ineffective management” could lead to, I would have been a better…manager. Alright, shake it off. Let’s not get dramatic here. Knowledge is power…and hindsight is 20-20.

    The fact of the matter is thickening feeds (whether corn or rice based thickeners, or commercially thickened formulas) are increasingly being used to treat infants with GER. One of the driving factors is the baby food industry. Once again, commercialization of infant nutrition is impacting how we care for our children. That’s part of the reason I think that evidenced based practice is so important—both as a clinician and as a mother.

    But, I’ll admit, that I didn’t do any research when my son was an infant suffering from GERD. This is all in retrospect. I was overwhelmed and research was the last thing on my mind. I didn’t research the literature; I didn’t even poll my circle of support at the time. I expressed my concern to my pediatrician and we went with the first recommendation she offered. Before turning to my pediatrician in desperation, I had tried the standard conservative approaches. I had already tried the elimination diet. He preferred to sleep prone and upright on my chest and—if and when he would let me put him down in his bassinet—I would lay him slightly on his left side. I stuffed blankets underneath the mattress to raise the head off the bed a bit too. Diet. Check. Positioning. Check.

    I would have tried smaller more frequent feeds, but my son was everything GERD described: My LO was projectile-vomiting at most feeds, crying inconsolably unless he was sucking on my boob or asleep on my chest. He would scream bloody murder if I set him down in his crib. I was tired and at my wits end. The last conservative treatment was rice cereal. But my pediatrician didn’t recommend it and I honestly don’t think I even considered it. She wrote a prescription for medication and we filled it. The medication didn’t resolve the vomiting but it certainly reduced the frequency of the vomiting episodes as well as the velocity of it. It was no longer making it well over both my shoulder and the back of the easy chair. It also reduced the intensity of his writhing, arching and crying. I knew he was still suffering from the reflux, but he was more comfortable and he was sleeping 4+ hours at night! That was enough for this mom to want to continue administering it.

    In retrospect, seeing all the moms who have given rice cereal to their infant in order to resolve reflux (whether by intuition or recommendation); I am wondering why we didn’t go that route first. Now that I’m out of the woods, have more regular sleep, I can now delve into the research.

    What is Reflux?

    The Happy Spitters |  Gastroesophageal reflux (GER) is when gastric contents pass into the esophagus. Basically tummy juices move up into the throat. Sometimes, tummy contents can come all the way up into the pharynx or even the mouth. Reflux is normal in infancy. Let me say that again. Reflux is normal in infancy.  It occurrs several times a day with each episode lasting less than a few minutes. Most of the time you won’t even notice it’s happening. Infants are predisposed to reflux because of frequent, large-volume feedings, shorter esophagus, and they typically are laid down after feeds.

    Yep, that’s all NORMAL. Regurgitation peaks around 4 months of age (50%) and drops to about 14%  by 7 months of age and less than 5% by 10-14 months old.

    The Unhappy Spitters |  Gastroesophageal Reflux Disease (GERD) is a whole other beast. This is diagnosed when there are complications of GER. It is typically classified as “esophageal” or “extra esophageal.” Esophageal GERD may present with symptoms such as poor weight gain, food refusals or prolonged feeds, irritability or chronic crying, recurrent vomiting, abdominal or substernal pain, and esophagitis. Whereas, extra esophageal-type GERD may present with respiratory disorders, chronic cough or hoarseness and wheezing.  Regardless of the classification, these infants are clearly not the “happy spitters”. GERD often persists beyond 18 months and has adverse effects on the well-being of the infant (not to mention, the parent too and I speak from experience.)

    Treatment

    For parents of the ‘happy spitter,” I send you a big hug and say, ‘this too shall pass,’ because, after all, it’s normal.  Parents of ‘happy spitters’ may try more conventional approaches to resolution such as lifestyle and dietary changes.

    • Offer smaller and more frequent feeds
    • For the nursing mother, eliminate dairy and eggs
    • Positioning: infants placed on their tummy and/or on their left (only if awake and monitored secondary to concerns for SIDS) or on their backs but upright. My LO preferred to be upright, prone on my chest.
    • Thickening feeds: yes, this is a common recommendation as a conservative treatment approach for treating GER. This is what we are here for, so I’ll break it down a bit more below.

    If this doesn’t work, after a few weeks, you may want to consult your pediatrician. Your pediatrician will want to help relieve symptoms, make sure your child is still growing and thriving, and should recommend a treatment approach that prevents or minimizes any complications or any adverse effects.

    If it is determined by your physician that your child suffers from GERD, he/she might suggest as a next step, a trial of acid suppression therapy or pharmacological treatments. Typically, a physician may recommend the trial for 4 weeks with follow-up to determine its efficacy. If it works, awesome; go with it.  If not, your child may warrant further diagnostic testing and/or a referral to a gastroenterology specialist. This is beyond the scope of my practice and well beyond the scope of this article. So let’s move along to why we have all gathered here today  Rice Cereal!

    Thickening Feeds (for example, rice cereal)

    In 2002, the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommended that until more research is available, “thickening agents and infant diets containing thickening agents should be used only for selected infants with failure to thrive caused by excessive regurgitation and used only in conjunction with appropriate medical treatment and supervision.”  (Horvath et al., 2008)  In other words, if you are going to go the route of thickening feeds even if it is with something commercially available like rice cereal – you should be under the medical supervision of a pediatrician.

    In 2011, The Food and Drug Administration issued a warning against commercially available thickening agents like “simply thick” for infants born before 37 weeks gestation due to risk of necrotizing enterocolitis.

    According to a systematic review of the research, thickening feeds is only moderately effective in treating GER in that it does not reduce the measurable reflux (pH/severity and duration) but does significantly reduce the number of vomiting episodes (Frequency). A reduction in vomiting episodes, in and of itself, can reduce caregiver stress and improve infant behavior state.  Thickening feeds was also associated with increased weight gain, which could be clinically significant over time. Thickening a 20kcal/oz. formula with 1 tbsp. of rice cereal increases the energy density to 34kcal/oz. Other harmful events were also associated with thickening feeds. When thickening with carob thickeners, diarrhea and allergic reactions were reported. Thickening with rice cereal was associated with increase in coughing. In addition, thickening agents may negatively affect the bioavailability of the nutrients in milk/formula which basically boils down to is that even if a baby isn’t vomiting as much or their eating has improved, a baby’s body has less ability to absorb the essential nutrients. Alas, the research is not definitive. But, it is enough to say that choosing to introduce rice cereal to address reflux should not be taken lightly and it is a choice to be made in collaboration with your pediatrician who can help guide and monitor your child’s progress and overall health.  (Horvath et al., 2008)

     

    References:

    Baird, D.C., Harker, D.J., Karmes, A.S. Diagnosis and treatment of gastroesophageal refluxing infants and children. American Family Physician 2015; 92/8: 705-717.

    Hegar, B., Vandenplas, Y. Gastroesophageal reflux: natural evolution, diagnostic approach and treatment.  The Turkish Journal of Pediatrics 2013; 55: 1-7.

    Horvath, A., Dziechciarz, P, Szajewska, H. The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics 2008; 122:c1268-c1277.

    Lightdale, J.R., Gremse, D.A. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013, 131/5:

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