A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

A. After a Nissen fundoplication, children are expected to gradually progress from clear liquids to full liquids and then to soft foods as tolerated. Tolerating a full liquid diet in a 6-year-old is appropriate and indicates that healing and postoperative recovery are progressing as expected. No revision is needed. B. Eating small, frequent meals is an appropriate non-pharmacologic management strategy for gastroesophageal reflux. It reduces gastric distension and decreases reflux episodes. This reflects correct understanding and implementation of dietary management. C. Proton pump inhibitors (PPIs) are most effective when taken 30–60 minutes before meals, typically before breakfast, because they block active proton pumps stimulated by food intake. This demonstrates correct medication timing and requires no change. D. This is correct and requires revision of the plan of care. Infants with gastroesophageal reflux may have mild regurgitation that is physiologic; however, weight loss is a red flag indicating possible gastroesophageal reflux disease (GERD) with inadequate intake or complications such as esophagitis. This infant may require further evaluation, potential feeding modifications (e.g., thickened feeds, positioning strategies), or medical intervention. Weight loss indicates the current plan is not effective and must be adjusted.