Reflux Medications

There is a new report about the risk associated with prolonged use of proton pump inhibitors (PPI) for gastroesophageal reflux (GER).  I have referenced this topic a few times previously.  A quick review: most infants reflux at least once daily.  This is mostly a benign condition; most babies will spit up and continue quite happily–BARF-smile-play. That was my experience with my youngest, Luke–nicknamed “the puke” at the time (now a handsome businessman aged 23).  Some won’t–but even there, the large majority of children who are a) very fussy and b) spitting up regularly are not suffering (a) BECAUSE of (b).  We infer GER in infants based mostly on parental history but its very inexact.  The children don’t complain of heartburn and cannot specifically localize their distress (pain?) as older people can.  Definitive diagnosis of GER requires endoscopy and biopsy, but given that this is very invasive, requiring sedation and considerable risk of complication, it is not done in most clinical situations.

So given the diagnostic uncertainty, my approach is to be as conservative as possible in a baby who is growing well and mostly playful.  Difficulty with sleep??? Don’t get me started!   

If we are going to treat, I try and keep it simple.  Formula changes are worth a try but are actually rarely effective (<5%).  I always recommend that only a dramatic improvement is real–“a little better” is usually observer bias (science speak for “wishful thinking”).  Smaller, more frequent feedings, frequent burping, positioning(keep baby upright for at least 1/2 hour after feeding), thickened feeding (1 tsp cereal: 2 oz formula) are all often helpful.

A small minority of children will experience more severe symptoms–poor weight gain, refusing to eat, vomiting blood.  Other more severe, if less reliable, symptoms include prolonged screaming and chronic cough.  In these cases, some medicine MAY be a reasonable try.  But we must be realistic.  There is substantial evidence that PPI’s are of no real benefit as well as studies that tie their use to some real risks : pneumonia and severe intestinal infections(clostridium dificile–“C dif”) due to the natural infection protection of stomach acidity neutralized; malabsorption of essential nutrients like calcium.  Now, the latest(as alluded above) is new information that strongly suggests chronic kidney disease with prolonged PPI use.

So the wisdom of medication for GER and the proper circumstances for its use are both limited.  Let’s keep that in mind.  Give me a call if your child is refluxing and you are concerned>  Let’s work on it together.

Send along questions and comments.  Thanks for following.

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