Overprescribing GERD Medications for Infants? Perhaps not
It is worrisome that babies with normal regurgitation or gatroesophageal reflux may be prescribed strong medication designed for the treatment of gastroesophageal reflux disease. A study just published in the November 2007 issue of the journal Pediatrics illustrates how difficult it is to differentiate between the baby with normal regurgitation and the one with GERD.
The study looked at the acid levels of infants prescribed PPI (Proton Pump Inhibitor) medications for regurgitation (spit up or vomiting). A pH probe test, considered the gold standard for diagnosing GERD, was performed on each infant in the study. The results showed that only a small percentage of the infants (8 out of 44) had abnormal pH probe test results indicating GERD. Further, stopping the PPI medication did not cause the symptoms to worsen. The authors concluded that the majority of babies in the study did not meet the criteria for GERD and therefore did not need PPI medication to treat the symptoms.
This study follows a recent report demonstrating an alarming increase in GERD medication prescriptions for infants and children. While there has been an increase in pediatric GERD, doctors and researchers are concerned that the sharp increase in GERD medication prescriptions may indicate that some infants and children do not have GERD and may be receiving GERD medications needlessly.
But as a parent and advocate for parents of infants to teens with GERD, I am concerned that this study and others will be misconstrued and cause babies to suffer. Here's why:
The PPI medications were developed to target the underlying mechanism of acid over production in adults. While more research is needed, it appears that motility (coordination of muscles and nerves to move food through the digestive tract) is the underlying cause of pediatric GERD. The motility medications that target the underlying cause of pediatric GERD have not proven to be effective and have a record of worrisome side effects. While many infants and children have benefited from PPI's, it is clear that a medication that targets the underlying cause of Pediatric GERD is still needed.
It is well established that PPI's are safe and effective for reducing stomach acid and healing esophagitis and ulcers. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) recommends a trial of acid suppression medication (H2 blockers or PPI's) when symptoms are suggestive of GERD. Infants and children with symptoms of GERD may be spared discomfort and sedation if a trial of medication is used rather than performing diagnostic testing to determine a diagnosis before initiating treatment. Further, it is not practical to perform a pH probe on every baby with symptoms of GERD at this time. A trial of medication is certainly a low risk treatment option for many diseases, not just GERD. Perhaps doctors and parents need to try a time limited trial of a H2 blocker or PPI with careful follow up care. Once a baby with worrisome symptoms is placed on a GERD medication, perhaps parents are reluctant to stop the medication and observe the baby. Doctors may need to spend extra time educating parents about the goal of the trial of medication and explain other proven treatment options such as giving the baby small, frequent meals, burping often and elevating the bed or crib.
While the pH probe is widely used to assess the acidity of the esophagus and stomach, there is evidence that the newer impedance testing may be more sensitive and yield more information, including acid and non acid reflux events. Only a few of the bigger hospitals have access to impedance testing so it is unlikely that it will be available to all of the patients in need of testing. Studies have shown that premature and term infants have more non-acid reflux than adults. However, the role of the non acid reflux events is not fully understood at this time. In the future, more sensitive testing may decrease the need to use a trial of medication to diagnose GERD, leading to a decrease in over prescribing.
My daughter Rebecca was the happiest baby on the block, gained weight, almost never spit up and nursed well from her first feeding. Yet, she wasn't diagnosed with GERD for two years despite the fact that she refluxed every day and every night, silently burning her lungs and causing damage. Her pH probe was abnormal but not off the charts. When she finally started treatment, a high dose of a PPI medication allowed her to sleep through the night within days of beginning the treatment. I am afraid that other little Rebecca's may be denied medication because they did not fit the classic criteria for GERD until months and years had passed and the damage was done. We do not want to go back to the days when we assumed all babies had a harmless condition called "colic" and sedated the mother or the baby (or both) and blamed poor parenting skills on the cause for the crying. Some babies appear to have Gastroesophageal Reflux (GER) or physiologic reflux, a normal pattern of spit up and vomiting. Yet, as the weeks and months go by, the symptoms may worsen or cause other complications such as breathing difficulties and poor weight gain. I am certainly opposed to over medicating babies with strong medication when it is not needed but as a parent, I would want to explore any treatment that has some evidence of helping. Parenting a baby who cries incessantly and vomits may trigger a frustrated and tired parent to get angry at the baby. I have talked to stressed and exhausted parents who have told me they could not take care of their family or earn a living due to the intensive needs of their babies. While we may be over medicating some babies, we might be helping other babies with unclear/atypical symptom patterns or those at risk for other consequences such as shaken baby syndrome or child abuse.
Over time, I hope that research will target the underlying causes of GERD and allow us to properly medicate and treat babies with GERD. It is hoped that we can identify and differentiate the babies with GERD from the babies with other causes of crying such as food allergy, milk soy protein intolerance, constipation and sensory/neurological problems.
I believe that doctors and parents need to think in terms of reducing symptoms and not in terms of reducing acid. We all need to work together to find ways to sooth our crying babies. They are crying for a reason. But when the day is done and I am getting ready to hold my crying baby for another long night, I hope the doctor will not send me home and tell me to just deal with it. I need real solutions and help today. In our present health care system, doctors and hospitals are not always equipped to support parent education and training. A few years ago, I started a model parent training program to teach parents to manage their high need babies and support their emotional needs. If this type of program was available in every community, perhaps parents would have the home care strategies they need to cope with their babies and decrease the need for a magic pill.