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.
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2. Morgenstein, “Gastroesophageal Reflux Disease in Infants.” CME material,Children’s Memorial Hospital. 2008. http://www.childrensmemorial.org/cme
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