How Does Thickened Formula Affect Reflux in Infants?

How Does Thickened Formula Affect Reflux in Infants? 1024 683 Mary Bates, PhD

Infants in the neonatal intensive care unit with suspected gastroesophageal reflux disease (GERD) are often fed formula with added rice cereal or other thickeners, despite limited evidence of its efficacy or long-term consequences. Additionally, the consequences of thickened feeds are not well-studied, says Sudarshan Jadcherla, MD, a principal investigator at the Center for Perinatal Research at Nationwide Children’s and the medical director of the Neonatal and Infant Feeding Disorders Program.

“The use of thickeners and thickened feeds comes with short-term and long-term side effects,” he says, which may include excessive weight gain, constipation, gastrointestinal dysmotility and necrotizing enterocolitis.

Dr. Jadcherla and colleagues recently conducted a crossover cohort study in 40 infants with suspected GERD at Nationwide Children’s. The study is published in the Journal of Parenteral and Enteral Nutrition. The team used 24-hour pH-impedance testing to compare the direct effects of rice-thickened formula versus routine feeds on GERD symptom characteristics.

The researchers report that thickened formula had no effect on acid reflux characteristics, other than reducing cough symptoms and the frequency and height of refluxate. All other symptoms were comparable regardless of formula thickness.

Dr. Jadcherla and colleagues also found that the effects of thickened feeds are further modified by the severity of acid reflux index (ARI). Infants with an ARI greater than seven, which is considered abnormal, had longer bolus clearance times after thickened feeds. This suggests that refluxed material remained in the esophagus longer, potentially delaying esophageal clearance amidst greater duration of esophageal exposure to refluxed material.

Overall, the researchers say their results suggest there are pros and cons of using thickened feeds: Although thickened feeds may help decrease weakly acidic reflux, they may not alleviate other troublesome GERD symptoms. Plus, all thickeners have associated risks and some negative side effects that necessitate further research.

Dr. Jadcherla says that clinical trials are needed to clarify objective indications and therapeutic use of thickened formula in this population, along with study of their side effects. He and his team have recently been funded by the National Institutes of Health to conduct a clinical trial to test the effects of natural maturation versus acid suppressive medications versus rice-thickened formula on infants with suspected GERD.

“This will be a randomized trial that will, hopefully, be able to answer all of the questions we have about when to use thickened formula,” says Dr. Jadcherla, who is also a professor of pediatrics at The Ohio State University College of Medicine. “With this clinical trial, we will determine the short- and long-term side effects, as well as the short- and long-term benefits, of thickened formula for infants with GERD.”



Njeh M, Sultana Z, Plumb T, Alshaikh E, Jadcherla SR. Comparison of direct effects of rice-thickened formula vs routine feeds on symptoms and gastroesophageal reflux indices: A crossover cohort study. Journal of Parenteral and Enteral Nutrition. 2024 Jan;48(1):64-73.

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About the author

Mary a freelance science writer and blogger based in Boston. Her favorite topics include biology, psychology, neuroscience, ecology, and animal behavior. She has a BA in Biology-Psychology with a minor in English from Skidmore College in Saratoga Springs, NY, and a PhD from Brown University, where she researched bat echolocation and bullfrog chorusing.