***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Thickening of formula feedings is part of the therapeutic approach for gastroesophageal reflux ( GER ) in infants . However , its mechanism of action , especially regarding the occurrence of nonacid ( pH > 4 ) GER , has not yet been clearly described . The aim of this r and omized , placebo-controlled crossover study was to examine the influence of formula thickened with carob ( St. John 's bread ) bean gum on acid and nonacid GER . METHODS Infants with recurrent regurgitation and without other symptoms were fed alternately ( A-B-A-B-A-B ) with thickened ( A ) and nonthickened ( B ) but otherwise identical formula . Documentation of GER episodes during the study was performed by simultaneous intraesophageal impedance measurement ( intraluminal electrical impedance ; IMP ) and pH monitoring . The IMP technique is able to detect bolus movements inside a luminal organ . The use of multiple measuring segments on a single catheter allowed the analysis of direction , height , and duration of the bolus transport . Continuous videorecording and visual surveillance of regurgitation frequency and amount result ed in a severity score . RESULTS Fourteen infants ( 42 + /- 32 days old ) were examined during 6 feeding intervals each for a total measuring time of 342 hours . A total of 1183 GER episodes and 83 episodes of regurgitation were registered . Regurgitation frequency ( 15 vs 68 episodes ) and amount ( severity score 0.6 vs 1.8 ) were significantly lower after feedings with thickened formula . The difference regarding the occurrence of GER documented by IMP was also pronounced ( 536 vs 647 episodes ) . Although not statistically significant , maximal height reached by the refluxate in the esophagus was decreased after thickened feedings . Mean GER duration and the frequency of acid ( pH < 4 ) GER were not altered . CONCLUSIONS Thickened feeding has a significant effect on the reduction of regurgitation frequency and amount in otherwise healthy infants . This effect is caused by a reduction in the number of nonacid ( pH > 4 ) GER episodes , but also because of a decrease of mean reflux height reached in the esophagus . However , the occurrence of acid GER is not reduced . The combination of IMP and pH monitoring allows the complete registration and description of these GER episodes . Thickening of formula feedings with carob bean gum is an efficient therapy for uncomplicated GER in infants Gastro-oesophageal reflux ( GOR ) occurs mainly during postcibal ( PC ) periods . The duration of PC gastric acidity and the incidence of GOR were analysed in 11 asymptomatic premature infants .  GOR was studied during PC periods of 120 min and also during the following 120 min defined as fasting ( FT ) periods . These infants were subjected to simultaneous continuous gastric and oesophageal pH monitoring using a double-blind crossover technique . Two formulae with different fat contents ( 2.6 vs 3.6 g/100 ml ) and different carbohydrate concentrations ( 8.1 vs 7.3 g/100 ml ; malto-dextrin 2.8 vs 1.9 g/100 ml ) were given . Gastric acidity ( pH<4 ) in the PC periods lasted significantly ( P<0.001 ) longer ( 68 min±10 ) with the low fat/high malto-dextrin formula versus 43 min±11 with the high fat/low malto-dextrin  formula . Oesophageal pH monitoring data were within normal limits for the total investigation time in all infants . During PC periods acid GOR was detected more frequently in the group with a low fat formula . More PC GOR was recorded when the gastric acidity time was longer An open multicenter study was performed to assess the efficacy and safety of alginic acid in two different dosages in 76 pediatric patients with gastroesophageal reflux confirmed by pH monitoring . Among the 69 patients in whom endoscopy was carried out before treatment , 18 had erythematous esophagitis and 5 had erosive esophagitis . Irrespective of the dosage used , the frequency of regurgitation and vomiting decreased significantly ( p < 0.00001 and p = 0.01 , respectively ) . Clinical and biochemical tolerance were outst and ing and no adverse effects were recorded . On the basis of these data , the recommended dosage is 1 to 2 ml/kg/day in divided doses after meals To evaluate a pre-thickened formula ( Enfamil AR1/2 ) for  regurgitant gastroesophageal reflux , 104 infants were enrolled in a 5-week , multi center , double-blind , r and omized , place bo controlled parallel group trial . The Enfamil AR group showed greater symptom reduction by the end of the first week : percent feedings with any regurgitation ( p=0.045 ) , total regurgitation volume score ( p=0.035 ) , and percent feedings with choke-gag-cough ( p=0.004 ) . The most symptomatic infants at baseline had a reduction in trouble sleeping significantly with Enfamil AR by the end of the study ( p=0.030 ) . This formula flows through a st and ard nipple , reduces regurgitation and choking-gagging-coughing within a week , and improves sleep in the most symptomatic babies by 5 weeks , without causing constipation Summary The role of delayed gastric emptying ( GE ) in the pathogenesis of gastroesophageal reflux ( GER ) in infants is controversial at present . GE has been shown to be altered by the composition and osmolality of the feedings . This prospect i ve study was undertaken to assess the changes in the GE and the percentage of time GER was detected by scintigraphy using three different formulas on consecutive days in infants with GER . Twenty-eight infants under 1 year of age diagnosed to have GER by extended intraesophageal pH monitoring ( pH being < 4.0 for > 5 % of the duration of the test ) , underwent scintigraphy on three consecutive days using the same volume per single feeding of a casein-predominant , soy , or a wheyhydrolysate formula in a r and omized order . The formulas were isocaloric . Gastric emptying and percentage of GER into the esophagus were estimated for 60 min following these feedings . Mean GER percent during the study was 20.39 , 17.68 , and 16.34 on casein-predominant , soy , and whey-hydrolysate formulas , respectively , and was not significantly different . Mean values of GE were 39.7 % , 44.6 % , and 48.5 % on casein , soy , and whey formula , respectively . No significant difference in GE was also observed between casein-predominant and soy formula . However , a significant difference was observed ( p < 0.05 ) on GE between casein-predominant and whey-hydrolysate feedings . Our data suggest that formula selection may be important in the treatment of conditions associated with delayed gastric emptying To determine whether thickening of infant formula feedings with rice cereal increases coughing , we studied 25 infants from birth to 6 months of age , referred for evaluation of gastroesophageal reflux .  Coughing was blindly quantified after each of a pair of isocaloric meals ( one thickened and one unthickened ) .  Coughing was more frequent after thickened feedings than after unthickened feedings We compared the efficacy of the prokinetic agent cisapride with that of Gaviscon ( an alginate/alkaline compound ) plus Carobel ( carob seed flour ) in the treatment of gastrooesophageal reflux ( GOR ) . Fifty infants with confirmed GOR received either oral cisapride ( 0.8 mg/kg/day ) or Gaviscon plus Carobel for one month in a r and omised , parallel group study . Parental evaluations , diary scores , and 24 hour lower oesophageal pH recordings before and at the end of each treatment were compared . In the cisapride group 14/26 ( 53 % ) were considered better by their parents compared with 19/24 ( 79 % ) of those who received Gaviscon plus Carobel .  Diary scores , range ( 0.00 - 1.00 ) , improved in both groups with the median change being greater in the Gaviscon plus Carobel group ( -0.21 ) than the cisapride group ( -0.15 ) . Five of 17 pH variables had significantly improved from baseline in infants who had received cisapride compared with 11/17 in those receiving Gaviscon plus Carobel . However , unpaired analysis of diary and pH data showed no significant differences between the two groups . We conclude that first line treatment of GOR with cisapride is no more effective than conventional treatment with Gaviscon plus Carobel We assessed the efficacy of a natural clay ( smectite ) on the frequency and the duration of acid ( pH less than 4 ) and very acid ( pH less than 3 ) gastroesophageal reflux ( GER ) measured by 24-hour continuous pH recording ( CPR ) . Twenty newborn infants were enrolled in this double-blind controlled study owing to pathological CPR in supine position . After inclusion , all the patients were maintained in the 30-degree elevated prone position and received either smectite ( 3 g/day ; n = 10 ) or placebo ( n = 10 ) for 7 days . On the 8th day , a second 24-hour CPR was performed in supine position . The postural therapy alone ( placebo group ) was followed by a significant decrease in the numbers of acid GER ( p less than 0.05 ) during the second CPR . The combination of postural therapy and smectite treatment was followed by a decrease in the number of acid ( p less than 0.05 ) and very acid GER ( p = 0.01 ) , the percentages of time spent at pH below 4 ( p less than 0.05 ) and 3 ( p less than 0.01 ) and the maximal duration of acid GER ( p less than 0.05 ) The aim of the present study was to compare the efficacy and safety of a new aluminium-free formulation of alginate with placebo in infants with recurrent gastro-oesophageal reflux . This was a double-blind , r and omised , parallel-group study conducted at 25 centres in the UK . Of the 90 paediatric patients recruited in a general practice setting , 42 were r and omised to receive alginate and 48 to receive placebo .  Infants were assessed before treatment and again after seven and 14 days of treatment . Analyses were based on the last , valid , non-missing observation for each variable for the intent-to-treat ( ITT ) population of 42  alginate  and 46  placebo patients . For the primary efficacy measure ( number of vomitting/regurgitation episodes ) , alginate was significantly superior to placebo ( p = 0.009 ) . For the secondary efficacy measure ( severity of vomiting ) , a trend in favour of alginate was observed ( p = 0.061 ) . Patients receiving alginate achieved superior assessment s of treatment outcome by both investigators ( p = 0.008 ) and parent/guardians ( p = 0.002 ) alike . In addition , alginate achieved a significantly greater reduction in the mean severity of vomiting episodes recorded in a daily diary compared with placebo ( p = 0.027 ) and result ed in more patients having at least 10 % symptom-free days ( p = 0.027 ) . For none of the variables measured did placebo have a superior effect . More than one-half of all patients experienced some adverse event , although no statistically significant differences were observed between the two treatment groups ( p > 0.1 ) , and adverse events accounted for withdrawal in only 12.5 % of the patients ( alginate , n = 4 ; placebo , n = 7 ) . Aluminium-free alginate demonstrated superior efficacy over placebo in treating recurrent gastro-oesophageal reflux in paediatric patients . The safety profile of alginate was similar to that of placebo 
    Output:
    
REVIEW ER 'S CONCLUSIONS There is no evidence from r and omised controlled trials to support or refute the efficacy of feed thickeners  in newborn infants with GOR .
Given the absence of evidence , we can not recommend using thickening agents for management of GOR in newborn infants