Efficacy and safety of non-pharmacological interventions for gastroesophageal reflux and gastroesophageal reflux disease in children: a systematic review

Background: Gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) are common in infants and children. Non-pharmacological approaches are widely used, but their efficacy and safety remain uncertain. This systematic review evaluates the current evidence on non-pharmacological interventions for pediatric GER and GERD. Methods: We conducted a systematic review following Cochrane methodology and PRISMA 2020 guidelines (PROSPERO: CRD420251041380). We included randomized controlled trials and systematic reviews of non-pharmacological interventions for GER or GERD in individuals aged 0-18 years. Eligible interventions included dietary modifications, positioning, alginates, probiotics, massage, and complementary therapies. Study selection, data extraction, and risk of bias assessment were performed in duplicate. Due to heterogeneity, meta-analyses were not conducted. Certainty of evidence was assessed using the GRADE approach. Results: We included 40 studies: 39 RCTs (15 crossover) and one systematic review. Most studies involved infants with uncomplicated GER or GERD. Interventions included dietary modifications (n = 25), probiotics (n = 3), alginates (n = 4), positioning (n = 6), and massage therapy (n = 2). Most trials reported regurgitation or Infant Gastro-Esophageal Reflux Questionnaire Revised as primary outcomes. Several interventions, especially thickened feeds, probiotics, alginates, and left lateral positioning, were associated with reduced regurgitation frequency. Risk of bias was frequently high, and GRADE certainty ranged from very low to moderate, depending on outcome and intervention type. Conclusions: Thickened formulas and alginates showed the most consistent symptom improvement in infants with GER or GERD, though overall evidence quality was low to moderate. Other interventions yielded mixed results. Non-pharmacological strategies appear generally safe, but further high-quality research is needed to support clinical decision-making.