GERD – TO TREAT OR NOT TO TREAT, THAT IS THE QUESTION (BUT JUST THINKING ABOUT IT GIVES ME HEARBURN)
Is reflux the new ADD/ADHD for babies, in other words is this being over diagnosed and over treated ? Does every baby that cries for no apparent reason, need to be fixed? Let’s weigh this out.
I can tell you for a fact, practitioners in general, have a very strong desire to HELP or we wouldn’t be in the business of healthcare. Yes, I said business as we also want repeat customers. This need to help is sometimes interpreted into prescribing or, at a minimum, suggesting SOME type of change in the way patients are doing things prior to coming to our office. When we don’t do this, there are people out there that feel they’ve wasted their co-pay and won’t be as likely to schedule with you again. I actually had a mom call one of my colleagues (a physician) one day and suggest she wanted her money back from the previous day’s visit because I didn’t prescribe an antibiotic for her child’s viral illness. Luckily for me, my colleague fully supported my decision and substantiated my diagnosis and treatment plan based on vital signs and lab work……sigh.
Reflux in infants is a relatively new diagnosis that we previously called “colic.” When my daughter was born in 1985, she was diagnosed, as having “allergies” at two weeks of age and the allergists and ENT docs wanted her to have her adenoid (yes, there’s only one) taken out. They also requested I stop breastfeeding. One of the best decisions I ever made in my life was to ignore both these suggestions.
Whenever something is new, we start looking for it in our differential diagnosis (meaning what COULD these symptoms be?) We don’t want to miss it, now that we have researched based evidence. Some studies suggest that 50-67% of all babies have GERD and that only 10-30 percent of these babies are being treated. Other authoritative sources report only 1 in 300 babies as actually having GERD. This may sound more reasonable, but the number of babies prescribed drugs for reflux is 10 to 15 times this amount.
Think what you want about those statistics. For me, I think GERD is still being misdiagnosed at times and mislabeled as colic. Quite frankly, I think we as practitioners, can be as perplexed as parents.
Having said that, I think medications are sometimes being thrown at parents without a lot of explanation and non-medicated resources for dealing with it are not given. Parents need time to DIGEST (pun intended) this diagnosis. Women, who have just finished a pregnancy, usually have an easier time in understanding what GERD feels like physiologically. During pregnancy, the size of the growing baby in your uterus squeezing out your innards (as my grandmother use to call them) insures that your sandwich stays up in your esophagus for quite some time after lunch, causing terrible hearburn…..thank heavens for TUMS.
So, what are the downsides to meds, if any? I think certain babies DO need treatment, as I don’t want them to have more permanent damage to their esophagus by having the acid burn through the mucosa and cause bleeding. Understanding anemia can also develop as well due to blood loss from these bleeding tissues.
Nobody wants to see babies in pain and nobody wants to suffer the wrath of having their newborns scream throughout the day for hours on end if it can be alleviated or even prevented. When I have a headache, I usually pop a couple Advil. Although that’s not for everybody, I know that’s right for me. If I’m in pain, I’m not going to be as productive as I could be and the pain is going to distract my thinking.
As parents, we sometimes make decisions for our babies differently. When pain is not ours, somehow, it’s not as bad. It’s like a mom with whom I emailed this morning. Her dentist wouldn’t use novocaine while filling a cavity because she didn’t think it was compatible with breastfeeding…….SERIOUSLY? OMG! The dentist preferred to err on the side of caution instead of doing her due diligence and researching this drug….anyway, sorry, I digress in anger.
Personally, before I treat it, I make sure that parents have tried every other recommendation, that doesn’t include me pulling out my prescription pad. Remember, babies are healthiest when breastmilk is fed exclusively and reflux is diagnosed less often when babies are not receiving formula. An even worse recommendation I’ve heard practitioners give, is for babies to switch entirely from human breastmilk to a hypo-allergenic formula liked Alimentum or Nutramigen. Not only is it difficult to find a formula that a food-allergic baby will tolerate well, but the loss of immune protection and enhanced gut healing from mother’s milk may make things worse for the already distressed infant.
So, here’s a rundown of the two main categories of medications currently used for reflux; PPIs (Proton Pump Inhibitors) and H-2 Blockers (Histamine-2 Blockers).
PPis – There are literally, hundreds of thousands of babies and children on Proton Pump Inhibitor medications each year in the U.S. (a total of 2 million children up to the age of 16). PPIs are meds that slow down the production of acid in the stomach – brand names Prevacid and Prilosec).
Zantac is a Histamine-2 blocker is a medication that quite simply blocks histamine (histamine is secreted when there’s an allergen in the gut). There are occasionally proteins in a breastfeeding moms diet that babies are sensitive/allergic to. Moms can, if they choose, embark on an elimination diet, knowing that the three main allergens are dairy, eggs and peanuts. Occasionally, babies are also sensitive to chocolate (sorry), corn, soy, shellfish, citrus, Elimination dieting can be challenging but the results can bring healthy rewards. Please supplement your diet with calcium and prenatal vitamins if you’re going to go this route.
When we suppress gastric acid, we should also know the benefits of it Gastric acid is an early line of defense against infection, and important for nutrition. By prescribing acid suppressing medications, especially PPIs, to infants without a true diagnosis of reflux, practitioners may be placing babies at a higher risk for infections like pneumonia and gastroenteritis. Giving PPIs to babies can also lead to abnormalities in the levels of essential minerals and vitamins, such as magnesium, calcium, and vitamin B12 (http://www.jpeds.com/ and http://www.sutterpacific.org/ Dr. Hassall)
Are these all-benign drugs? No, but does the benefit outweigh the risk? You’ll have to be the one to decide. Just remember, not EVERY baby needs meds every time, but SOME babies need meds some of the time, because for them, the benefits DO outweigh the risks and the results can be pretty darn dramatic.
1. Stavroulaki, “Diagnostic and management problems of laryngopharyngeal reflux disease in children.” Int J Pediatr Otorhinolaryngol. 2006 Apr;70(4):579-90.
2. Morgenstein, “Gastroesophageal Reflux Disease in Infants.” CME material,Children’s Memorial Hospital. 2008. http://www.childrensmemorial.org/cme
3. Aanen et al., “Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care.” Aliment Pharmacol Ther. 2006 Nov 1;24(9):1377-84.
4. Omari et al., “Effect of omeprazole on acid gastroesophageal reflux and gastric acidity in preterm infants with pathological acid reflux.” J Pediatr Gastroenterol Nutr. 2007 Jan;44(1):41-4.
5. García Rodríguez et al., “Use of acid-suppressing drugs and the risk of bacterial gastroenteritis.” Clin Gastroenterol Hepatol. 2007 Dec;5(12):1418-23.
6. Karkos and Wilson, “Empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review.” Laryngoscope. 2006 Jan;116(1):144-8.
Read a post of www.secretsofbabybehavior.com and thought it was worth re-posting
TUESDAY, AUGUST 21, 2012
Reader Question: Variation in Breastfeeding Frequency
Recently, a reader asked us why her 8-week-old baby was still nursing every 2 hours when her friend’s baby (just a couple of weeks older) began nursing every 3 to 4 hours around the same age. Both babies are healthy, nursing well, and gaining the right amount of weight. In this post, we’ll share some information about differences in how often moms breastfeed even when babies are the same age and size.
Differences in Moms and Babies
Because most breastfeeding moms don’t see how much milk their babies get, they don’t know how much milk volumes can vary from one mom to the next or even from feed to feed. Moms may assume that their babies take about the same amount of milk as their friends’ babies but there can be big differences even when babies are about the same age. For example, breastfed babies take an average of about 27 oz per day from 1 to 3 months of age but that amount can vary from mom to mom by as much as 25%. Why so much difference? There are a few reasons why:
Moms vary in how much milk they can “store” in their breasts. The amount is limited by the milk producing structures that are in her breasts after lactation is established. Studies in Australian showed that this “storage capacity” can vary from just under 3 oz to over 20 oz! Moms also can have different storage capacity in one breast versus the other.
The fat content and the calorie content of milk also varies from one mom to the next. While the type of fat in mom’s milk is affected by diet, the total fat and calories in milk are not. Total milk fat content is related to mom’s biology and tends to be the same for all of her children. So, some moms make “2% milk” and some moms make “whole” milk and others are in between.
Babies vary in how much milk they need to take each day. Some grow very fast and some a little slower, some healthy babies are very big and others are smaller.
The amount of milk that babies can drink all at once also varies quite a bit. While all young babies have tiny stomachs, some are physically able to take more than other babies and others a little less.
Moms and Babies Work Together
When moms are responding to their babies’ cues when feeding, most babies are good at taking as much milk as they need to get enough calories to be healthy and grow. But, since moms are also part of the picture, babies will differ in how often they need to feed based on mom’s storage capacity and the calories in her milk. If a mom has higher fat milk, a big storage capacity, and a baby who can take a lot of milk at once, she can go longer between feeds (like the 3-4 hours for the friend in the story above). But, if she is a mom with a lower storage capacity, lower fat milk, and a smaller baby, she’s going to need to feed more often so that her baby gets all the calories she needs (like every 2 hours). As babies get bigger, they will be able to take more milk at once and get closer to moms’ capacities. They also build their own “storage” (baby fat) that helps them go longer between feeds.
If you are a worrier, you might be thinking that you’ll end up with low fat milk and a small capacity combined with a bigger baby who can’t take much milk at once. While that is possible, it’s not common. Even then, a baby who nurses a lot gets a lot of practice and with a lot of practice, babies get very efficient (and quick) at nursing so the total time spent nursing may not differ much from moms who don’t have to nurse as often.
R.A. Lawrence. Breastfeeding: A Guide for the Medical Professional. Saunders, 2010.
Daly SE, Kent JC, Huynh DQ, Owens RA, Alexander BF, Ng KC, Hartmann PE. The determination of short-term breast volume changes and the rate of synthesis of human milk using computerized breast measurement. Exp Physiol. 1992;77:79-87.
AS I BEGAN TO WRITE A BLOG ENTRY ON PPD, I RECEIVED A LINK TO ANOTHER BLOG FROM A FRIEND OF THIS MOM, WHO EXPERIENCED PPD FIRSTHAND. SINCE IT IS THE MOST MOVING ACCOUNT I’VE EVER READ, I’M POSTING IT VERBATIM. (I have permission to share with you).
THE ORIGINAL POSTING CAN BE FOUND AT:
FACING THE REALITY OF POSTPARTUM DEPRESSION.
JUL. 31, 2012 AT 5:23AM
It was just after 5 am. I was staring at my husband under the bright white lights from my hospital bed in the delivery room. I was trying to channel him, to see if he was feeling “that thing” that everyone said we would feel—that joy, that euphoria of being a new parent.
I didn’t feel it. Actually, I felt nothing; I was numb.
I drifted through the next few days telling myself I was happy, smiling for visitors and photos. But when no one was around, the demons danced in my head. I was terrified. I didn’t want to be alone with that thing: my baby.
And then it got worse. My daughter started crying. Colic, but I didn’t know it at the time; I only knew I was a terrible mother. I knew I had made an awful mistake having this baby. When she cried, I cried harder. I would pace the house and feel the anger boiling inside of me. I ate very little. I slept even less.
A friend gave me advice to go for a walk with the stroller if she got “fussy”, so I walked furiously for hours every day. I did the same one-mile loop around my neighborhood five or six times a day. These walks took me to dark places; I often stood at the top of a particular hill along my route with the stroller and thought about what would happen if I just… let go. I imagined this every time I was on that hilltop. I hated myself each time, and it reinforced my feelings of failure as a mother, even though I was pretty sure I could never actually do it.
I spent each day miserable and anxious. I toggled between feeling sorry for myself and feeling ashamed at what a terrible mother I was. I continued to cry; sleep continued to elude me. And as the months passed, she stopped crying… but I could not. In fact, I didn’t even notice that she was getting calmer. I was in a constant state of emergency.
When she started sleeping through the night, I still rarely slept more than three hours. I stared at the ceiling for hours, focused on the enormous pit in my stomach. I started each morning with an overwhelming wave of dread about the day ahead of me. I tried to come to terms with this new life. I had done this to myself—I chose to have a baby—and so this misery was the price I had to pay. I would never be happy again.
After a long maternity leave, I was ready to return to work. I told myself the dark cloud might lift a little once I was back to my normal routine at work. But that’s not what happened. The first day at work, I cried —not because I missed my baby, but because I was overwhelmed by my life. The second day, I told my boss I was thinking about quitting, and I cried some more. The third day brought even more crying—I felt hopeless and alone.
On the fourth day, my boss, who has known me well for nearly ten years, called me into her office. She told me I was not myself. She asked me to go to the doctor and take some more time off work.
I shudder to think what would have happened if she had not said those words to me. The trip to my obstetrician’s office is a blur, but I have a vivid memory of the nurse taking my blood pressure and asking, “What brings you in today?” I opened my mouth to tell her, but no words came out. Only sobs.
Thus began my journey out of postpartum depression.
There is much more to this story: panic attacks, suicidal thoughts, medication, hospitals, and guilt beyond imagination. But this story has a happy ending. My daughter just turned two years old. I feel a stronger bond with her now than I ever could have thought possible. We survived that struggle together. She is the best thing that ever happened to me.
There are countless things I wish had been different. What I went through is no one’s fault (including my own, I just wasn’t aware of that then). But if Postpartum Depression was easier for us to talk about, I could have gotten help sooner. Common mindsets about mental health and PPD are often uninformed, preventing people from getting the help they need.
Do you know anyone who has suffered from PPD? I bet you do. One in five mothers will experience anxiety or depression during pregnancy or the first year following delivery, and it is the number one complication of pregnancy and childbirth. The most frustrating fact is how truly treatable this problem is. If we can talk openly about how new moms are feeling, then we can prevent PPD from having such a deep and lasting effect. The message I send to every struggling new mom is this:
You are not alone. You are not to blame. And with help, you will be well.
Nadia Monroe is the founder of Postpartum Support Maryland, an affiliate of Postpartum Support Virginia, providing resources for struggling moms in the MD,VA, DC area. She lives with her daughter and husband in University Park, MD and, in addition to her volunteer work, works full time in Human Resources. For more information, to get resources, or to join the discussion, please visit www.postpartumva.org
Posted in General, Journal by Nadia Monroe
Sometimes it’s clear-cut and other times, well…..it takes us a little longer to figure out exactly what’s causing the chronically sore nipples mom is experiencing with breastfeeding. With an anterior tongue time, a rooky could spot it. You can see the tongue tethered to the bottom of the FRONT of the tie. Some are so tight, that the tongue actually comes into a “heart-shape” when the baby cries. One quick, clean clip, one drop of blood, and the fear of nursing disappears. Additionally, the high risk of speech-language problems down the road, may also be erased.
Parents often show me their own tongues when I ask “who else in the family is tongue-tied?” Some of these moms and dads had been through speech-language therapy and others tell me that they never found it a problem at all. One mom told me her own mother wasn’t able to breastfeed her as a baby and never knew why, until I pointed out that she couldn’t even stick her tongue out. Isn’t that a prerequisite to being a little kid? I mean, what are you going to do when another kid is mean to you……hello?
I admit that, before I understood the difference between an anterior and posterior tongue -tie, I worked more with moms latching than babies sucking. Then I realized, after attending a conference, how to detect and diagnose this phenomenon. You have to place your index fingers (pointing in) on either side of the underneath part of the tongue and……low and behold……a little string-like frenulum may just pop up.
That little string is called a posterior tongue-tie and can cause just as many problems as the more obvious anterior tongue-ties. When you sweep your finger under the tongue from one side to the other, you actually feel a little speed bump.
Last week, I was told by one of my moms, that her husband had taken care of her tight frenulum….I then asked if he was a dentist or ENT surgeon….but NOOOOOO, it turns out that he’s just a really, really “passionate” kisser!!!! Yup, he broke her frenulum with his own tongue….YIKES!
My final problem is called a tight labial frenulum and it’s located in the middle, under the upper lip. Many kids break them during toddlerhood when they fall and hit their mouths on a coffee table or some other lovely item in the home. When left unclipped, they can result in a gap-toothed smile (ala David Letterman). Dentists usually discover them and sometimes want them clipped before the permanent teeth erupt. With babies, it can prevent them from curling up their upper lip to help latch at the breast.
One key to solving tongue-tie problems, as described above, is to find an experienced lactation consultant and ENT surgeon, who specialize in diagnosing and understanding how tongue-ties can negatively impact a nursing relationship and milk supply.