Rice Products to be Avoided in Thickening Feeds for Pediatric Patients with Gastrointestinal Reflux Disease

CLINICAL QUESTION

What are pediatric and gastrointestinal medical societies’ recommendations regarding the use of rice in thickening feeds for pediatric otolaryngology patients with gastrointestinal reflux disease (GERD)?

BOTTOM LINE

Otolaryngologists charged with the care of infants affected by GERD should advocate for the avoidance of rice products in thickening feeds and opt instead for safe alternatives such as oatmeal, barley, wheat, and maize.

BACKGROUND: When regurgitation in infants is accompanied by symptoms such as high volume and frequency, feeding refusal, or failure to thrive, GERD is diagnosed. Rice products are often used to thicken feeds in treatments for infants with GERD, but these products have been found to contain unsafe levels of inorganic arsenic.

STUDY DESIGN: Commentary

SETTING: Department of Otolaryngology–Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas

SYNOPSIS: In this commentary, the authors note that the first step in treating infants with GERD is diet modification, followed by thickening feeds and/or a maternal diet elimination of dairy and soy for breastfed infants. Thickeners may be artificial or natural, but most artificial thickeners are not recommended for infants. Natural thickening products may be manufactured from rice, wheat, oats, xanthan gum, or guar gum, among others. Authors report that the literature surrounding thickening feeds strongly recommends against rice thickeners due to unsafe levels of inorganic arsenic naturally found in rice. Due to their smaller size, infants consuming rice-thickened feeds take two to three times the concentration of arsenic per kilogram than the average adult. Chronic exposure to inorganic arsenic has been associated with skin, lung, and bladder cancers, among other health risks. The authors note that leading pediatric and gastrointestinal medical societies have called for the regulation of inorganic arsenic contents, cessation of rice thickening in infants and young children, and substitution with other grains. The researchers emphasize that otolaryngologists charged with the care of infants affected by GERD need to be aware of this near-ubiquitous source of inorganic arsenic, a proven carcinogen.

CITATION: De Jong RW, et al. Arsenic in rice: a call to change feeding substitution practices for pediatric otolaryngology patients. Otolaryngol Head Neck Surg. 2025;172:369-371. doi:10.1002/ohn.1029.