I've been noticing an alarming trend in the pediatric patients that I encounter in my practice, as well as the children of my family and friends. Babies are being prescribed powerful acid-suppressing medications by their pediatricians. The reasons why infants are being given medications to suppress stomach acid include the following common symptoms:
- Spitting up or vomiting "too much" or "too often"
- Colic or other unexplained excessive crying and irritability
- Frequent or wet hiccups
Other (more serious and concerning) symptoms of gastroesophageal reflux in infants may include:
- Chronic cough and/or congestion
- Gagging or choking during and/or after feedings
- Poor feeding habits, feeding refusal, or aversions
- Wheezing or breathing problems
- Poor growth rate or failure to thrive
Medications to treat gastroesophageal reflux disease (GERD) are among the most frequently prescribed drugs for infants. The latest available data indicate that there was a sevenfold increase in the use of prescription drugs for infants diagnosed with GERD from 1999 to 2004 (see this study). Anecdotally, I suspect that the use of these medications has increased even more in the last few years. The rapid increase in the diagnosis and treatment indicates a strong possibility that GERD is both over-diagnosed and over-treated in infants. Even conventional medicine acknowledged this in a recent study. Infants are most often prescribed medications for the less concerning symptoms of reflux, such as spitting up "too frequently" or having unexplained crying fits.
It is important to note that some amount of spitting up is completely normal. Most babies spit up and it is especially common in the first 3 months of life. The majority of children will stop spitting up by 12 months of age. Spitting up is common in infants because their stomachs are quite small and can become easily distended during feedings. At the same time, the lower esophageal valve is immature and opens easily to a short esophagus, allowing the stomach contents to reflux. Prescribing acid-suppressing medications for frequent spitting up may often be nothing more than the medicalization of a normal infant behavior.
Numerous studies have demonstrated that acid-suppressing drugs are not effective for the treatment of GERD in infants (see this review and this review). In addition to a lack of efficacy, there are safety concerns with the use of acid-suppressing drugs in infants. Although proton pump inhibitors (PPIs) are frequently prescribed to infants as an off-label use, no PPI has been approved by the FDA for use in infants less than 1 year of age. And within any age group, no PPI has been approved to be used on a long-term basis. Most are indicated for use on a short-term basis from 8 - 16 weeks. The Pediatric GERD Clinical Practice Guideline cites several safety concerns with the use of acid-suppressing drugs in infants, including known adverse effects that include head banging, headache, persistent sleepiness, diarrhea, constipation, nausea, gastroenteritis, increased risk of pneumonia, and increased risk of liver disease. PPIs are also known to alter the gut flora, which play a large role in overall health and normal functioning of the immune system. In 2012, the FDA issued a safety warning about the increased risk of C. difficile infections with the use of PPIs, which is due to the effect that PPIs have on disrupting the delicate balance of the gut flora.
Even beyond all of these considerable safety concerns, acid-suppressing drugs have serious consequences on the functioning of the digestive system in infants. Stomach acid is necessary for the proper digestion of food! Stomach acid has several important roles including:
- Breakdown of proteins into a form that they can be digested (called proteolysis).
- Activation of the enzyme pepsin, which is responsible for protein digestion.
- Inhibiting the growth of microorganisms that enter the body through food to prevent infection.
- Signaling when the food (referred to as chyme) is ready to leave the stomach and move into the small intestine for continued digestion.
When stomach acid is suppressed, a whole series of events occur that compromise digestive function. Eventually, this can lead to digestive problems, leaky gut syndrome, and systemic health problems. Instead of using acid-suppressing drugs in an attempt to mask symptoms, it makes much more sense to get to the root cause of what is behind persistent and distressing symptoms of reflux in the infant.
In Part II of this series, I discuss how to holistically approach symptoms of reflux in the infant and get to the root cause. I'll leave you with a clue...it starts with nutrition of both mom and baby!
Was your baby diagnosed with GERD? What treatments did you try? Were they effective?
Barron, J.J., Tan, H., Spalding, J., Bakst, A.W., & Singer, J. (2007). Proton pump inhibitor utilization patterns in infants. Journal of Pediatric Gastroenterology and Nutrition, 45(4), 421 - 427.
Higginbotham, T.W. (2010). Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Annals of Pharmacotherapy, 44(3), 572 - 576.
Scherer, L.D., Zikmund-Fisher, B.J., Fagerlin, A., & Tarini, B.A. (2013). Influence of "GERD" label on parents' decision to medicate infants. Pediatrics, 131(5), 839 - 845.
van der Pol, R.J., Smits, M.J., van Wijk, M.P., Omari, T.I., Tabbers, M.M., & Benninga, M.A. (2011). Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: A systemic review. Pediatrics, 127(5), 925- 935.
Breastfeeding Infant: PublicDomainPictures.net, 2011.
Stomach: Wikimedia Commons, 2005 (Arnold Reinhold).