Paeds Cases · gastroenterology-hepatology-and-nutrition
Gastro-oesophageal reflux and reflux disease — clinical case
Clinical case of a thriving unsettled formula-fed infant with posseting and back-arching, illustrating the conservative-first management ladder, exclusion of cow's milk protein allergy, and restraint with acid suppression.
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RACP DCEMRCPCH ClinicalABP General Pediatrics
Prompt
A 4-month-old term infant, exclusively formula-fed, is brought to clinic with frequent small effortless posseting within an hour of feeds since the early weeks, crying, and back-arching after feeds. Weight tracks the 50th centile, the abdomen is soft, the vomit is never bile-stained or bloody, and there are no respiratory symptoms. The parents are exhausted and want a proton-pump inhibitor started.
Case summary
This thriving infant has effortless posseting with crying and back-arching but no red flags — a textbook picture of physiologic gastro-oesophageal reflux rather than disease. The clinical skill on display is restraint: resisting the request for a proton-pump inhibitor, confirming that this is physiologic reflux, excluding cow's milk protein allergy, and managing conservatively while supporting an exhausted family. [1]
References3ShowHide
- [1]Rosen R, Vandenplas Y, Singendonk M, et al Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr, 2018.PMID 29470322
- [2]Orenstein SR, Hassall E, Furmaga-Jablonska W, et al Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr, 2009.PMID 19054529
- [3]Banderali G, Mameli C, Bozzola E, et al Efficacy and safety of non-pharmacological interventions for gastroesophageal reflux and gastroesophageal reflux disease in children: a systematic review. Ital J Pediatr, 2026.PMID 42098776