Thank you Dr. Hassall for bringing up the overprescription of PPIs in infants and I would extend this concern to children as well. It seems as though PPIs became so common place when they went OTC that it seemed normal to prescribe them. Like Jan, I think that if a child does not respond after a trial of them, then the child should be taken off of them and other things considered.
I do worry though that when doctors assume true GERD is very very rare except in when there is an underlying condition, that children like mine are missed. My daughter suffered from severe reflux from birth. We assumed that she, like me, was colicky and we chose to try lifestyle things and await the magical day when things would get better. At 6 months she stopped spitting up and we rejoiced. Unfortunately, she was then a silent refluxer and over the next month she became hoarse, stopped eating, stopped sleeping, and lost weight. At 7 months, she was put on Zantac and within days was a much better baby. She was then medicated until 4 years of age and then again started meds at 9 when asthma meds weren't taking care of a chronic cough but reflux meds did.
My second son was medicated at one month, my third at 1.5 weeks when he was gasping for air after refluxing. By my third, the first drug of choice was Prevacid. Looking back, I think it would've made more sense to try him on an H2 blocker first.
Did the meds make my kids happy kids who didn't cry? No! They were still all miserable colicky babies. But, they were able to eat, sleep more than without meds, gain weight and breath. Did I hate hearing them cry? Sure, but I certainly didn't choose to medicate them just because of this. Medicating them was a difficult but eventually necessary decision.
I think we need to find a happy medium between assuming that babies are all colicky just because they can't tell us their throats burn horribly and over medicating babies simply because they have immature nervous systems and are "cranky" or "colicky."
Thanks again - Stephanie
Hi Stephanie: thanks for your comments. No question but that you are correct - while acid suppressing drugs, especially PPIs, are overprescribed in infants (ie, under the age of 12 months), the diagnosis of GERD, ie, reflux disease, may indeed be missed in individual cases. My sharepost refers to overall numbers - but certainly in all age groups, reflux disease can be missed in individual cases.
And this is why careful individualized medical evaluation is required. Even if, just for example, 95% of infants receiving a PPI did not require the drug, for the child who does have reflux disease, and in whom the diagnosis is missed - it's 100% misdiagnosis. The numbers tell the overall story - that is, that the drugs are overprescribed - but the numbers don't make the diagnosis in the individual case. For that, you need a doctor. Kind regards, Eric
I'm curious what you think about long term use of PPIs in children? With the new studies coming out showing increased risk of fracture in the 50+ crowd, I'm concerned about the kids who are taking it at time when they should be building up to their peak bone mass.
I also work as a pediatric PT and see kids who are already at risk of fracture for various reasons on them for years and am wondering what additional risk the PPIs are causing.
Have you heard of any studies of kids on PPIs long term? My pediatrician was surprised to hear from me about the studies in the 50+ crowd because of course it is not in the pediatric literature.
My 10 year old has a chronic cough that we can only get rid of with reflux meds. During cold and flu season we have to bump her to PPIs but can generally get her back down to H2 blockers but we can't get her off of it. It's more than a bothersome cough as it makes her very dizzy at times and keeps her from being able to fully participate in activities.
Any thoughts on this group of kids?
Thanks - Stephanie
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Hello Dr. Hassall and welcome to HealthCentral!
I know you have studied infant reflux for quite some time and have a great deal of information to share with us. I look forward to reading your future posts.
I think parents are just as concerned as doctors about the best way to treat infant crying, infant reflux and GERD. I don't think any parent or doctor would give a strong medication such as a Proton Pump Inhibitor (PPI) to a spitty baby. It get complicated for everyone when the baby is struggling to eat and sleep day and night due to crying. This unexplained crying sure if awful to listen to and seems to indicate that something is terribly wrong. Parents are hard wired to fix the hurts-I can certainly relate to a parent who brings a inconsolable baby to the doctor who requests or even demands some type of treatment. I know the new GERD treatment guidelines for treating infant reflux indicate that sometimes a short term (2-4 week) trial of anti reflux medication may be needed in some cases. If there is no change in symptoms, the medication should be stopped. If there is a positive change, the medication may be continued but carefully monitored by the doctor. I do get concerned when I hear a parent tell me that the baby has been on a treatment such as medication for months and months and there is no change in symptoms. Perhaps some of these babies are part of the dramatic increase in medication usage you mentioned in your post.
Best wishes,
Jan Gambino
Many thanks for your warm welcome, Jan. I've pasted your some of your comments in, and addressed them as follows:
JG: I don't think any parent or doctor would give a strong medication such as a Proton Pump Inhibitor (PPI) to a spitty baby.
EH: On the contrary - that is exactly what is happening. Because, when there is a 'spitty baby', who is also irritable - albeit for likely a reason not related to the spitting - which is a normal occurrence in most - that 'spitty baby' is assumed to have GE reflux disease, ie, so-called 'acid reflux'.
JG: It gets complicated for everyone when the baby is struggling to eat and sleep day and night due to crying. This unexplained crying sure if awful to listen to and seems to indicate that something is terribly wrong.
EH: Quite true - it is very disconcerting and concerning for parents to have a baby in distress. But those symptoms are much more likely to be due to a cause other than reflux disease (so-called 'acid reflux'.) And it woud be yet more distressing to have an infant prescribed an acid suppressing drug for a condition which is not reflux disease, and to have an adverse event from the drug. We know that acid suppressing drugs are accompanied by an increased incidence of infections - respiratory and gastrointestinal. And in our study, 12% of infants on the drug developed a serious adverse effect, including pneumonia, whereas none of those treated with placebo did.
JG: I know the new GERD treatment guidelines for treating infant reflux indicate that sometimes a short term (2-4 week) trial of anti reflux medication may be needed in some cases. If there is no change in symptoms, the medication should be stopped. If there is a positive change, the medication may be continued but carefully monitored by the doctor.
EH: that is all correct. The operative word is 'sometimes'. And in most cases, a different approach will be indicated. Such as removing antigens from the infant's diet - 'non-pharmacologic treatment'. I will write further on this approach.
JG: I do get concerned when I hear a parent tell me that the baby has been on a treatment such as medication for months and months and there is no change in symptoms. Perhaps some of these babies are part of the dramatic increase in medication usage you mentioned in your post.
EH: the data from a large survery of prescribing habits in the US show that most of the infants given an acid suppressing drug were prescribed it before the age of 4 months - an age range when reflux disease is simply hardly ever present - an age range in which the diagnosis is usually 'colic' and can be treated without acid suppressing drugs.