Doctors are overprescribing antireflux medications in infants, according to a new study released today in Pediatrics. Gatroesophageal reflux disease (GERD) occurs when stomach acid goes the wrong way, flowing back into the esophagus. It's caused when a valve between the esophagus and stomach does not close properly. But how common is it in colicky infants? And why are we seeing an increase among children in the use of a class of drugs called proton pump inhibitors, the most powerful of three major classes of antacids?
To find out, the researchers measured the reflux or regurgitation of acid from the stomach into the esophagus of 44 infants in a New Orleans medical center. They found that while only eight of the infants had abnormal pH levels indicating GERD, 42 of 44 infants were on antireflux medication. When medication was withdrawn from the infants who did not meet GERD criteria, reflux symptoms did not worsen.
One concern with overtreatment is that there are currently no known safe or effective dosages in infants, because the drugs are prescribed off-label to children. Another issue stems from a study in the Journal of the American Medical Association that found long term use of proton pump inhibitors, particularly at high doses, is associated with an increased risk of hip fracture, said New Orleans pediatric gastroenterologist Vikram Khoshoo, lead author of the Pediatrics study. "Older people are not laying down new bone. Younger people are," Khoshoo told me. "There’s a lot of concern emerging, especially for children. Are we going to be changing bone mineral content? Do we have any data? "There's a lot of parental anxiety and impatience that gets fueled by a doctor...who wants the mom off his back," Khoshoo said. "A kid spits up a couple times and everyone freaks out... Then a mom comes in and says, 'fix my kid!' (so they prescribe the medication). It's the same story with colds and coughs and antibiotics: parental impatience." (Antibiotics, which are used to treat bacteria, are ineffective against colds, which are caused by viruses.)
Khoshoo said there's also a misconception among parents that PPIs will decrease regurgitation. They actually work by shutting down acid production but this won't necessarily reduce spit-ups. "So if you have a child with regurgitation who is very irritable because of heart burn and you put this unhappy spitter on antacids, you're simply converting him to a happy spitter. The spitting (up) doesn't change. If the child is spitting up, it's a laundry issue, not a medical issue."Untreated, chronic GERD, of course, is a real issue. It can cause ulcers, bleeding from the esophagus lining, narrowing of the esophagus and Barrett's esophagus, which is a change in the cellular makeup of the esophagus that boosts the risk of esophageal cancer.
But drugs are not the only way to fight it. Lifestyle, including alcohol use, smoking, obesity and pregnancy as well as citrus fruits, chocolate, garlic, onions, spicy food and tomato-based foods all can cause GERD symptoms. For infants, who hopefully don't have any pre-existing alcohol, smoking or weight issues, Khoshoo recommends two simple tools: reassurance and conservative management."If your child is gaining weight, happy, feeding well and does not have recurrent respiratory problems, then it's uncomplicated reflux," he said. "Just because he's throwing up a lot and parents are anxious is not a reason to succumb (to medication). Just give them reassurance, that's it. There's no copayment or price tag. With time, some things get better."Regurgitation, he said, is usually just a maturational problem."Why do old people lose hair?" he asked. "Most of these kids will get better by 18 months."
Bonnie - hallelujah! I wrote about this in 2005 when I wrote Reverse Reflux in Your Child Action Plan. Hopefully this study will create a downward trend in prescribing this for young children.
2 comments:
Your article, while interesting, is obviously not written from the perspective of a parent dealing with GERD in their infant. There are a lot of us who worked tirelessly to get our children diagnosed. In the mean time they became FTT or aspirated due to their GERD. One of ours almost died due to it.
While parents need to understand that it is the acid being treated not the vomit, physicians also need to understand that there are a lot of children whose GERD goes untreated.
The LES is NOT a valve but rather muscles that tighten or loosen depending on need and acts similarly to a valve. It often does not function correctly in premature infants, those with neurological diseases and/or hypotonia. There are also kids with no known risk factors that have a lot of problems as well.
As far as the study is concerned it is important to note weather the participants were on acid reducing medicines at the time of the testing. If they were it is likely that the only thing the testing showed was that the children were gaining benefit from the medicines. Once removed it may take quite some time for the damage to recur. It would be interesting to see long term how those kids ended up doing.
It is also important to note that the lifestyle changes you noted do not apply to infants. You may wish to educate readers about positioning techniques, proper burping and smaller more frequent feeds for infants.
All parents should discuss the nutritional implications of PPI use as you noted. They may be able to offset these losses by proper nutrition or supplementation. It is also important to discuss weaning from ANY medication when it is no longer needed. Weaning appropriately may be more of an issue that the original need for PPI's in my opinion. We certainly found that to be an issue in our case.
All that having been said, my children would have DIED without proper treatment for GERD. Though you noted some of the bad/scary effects it is quite important not to downplay those. This is a serious medical issue for some children, even to the point of requiring tube feedings. The goal of all health care professionals is accurate diagnosis and proper treatment. That would prevent kids from suffering needlessly as well as preventing children from being put on medications that they do not need.
The basic cure for gerd symptoms begins with changing unhealthy lifestyle.
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