Reflux redux

Let’s circle back to review a common problem which I have referenced previously–colic and reflux (GER) in infants.  A recent journal article looked at the use of medication in preterm infants with this condition.  I think the results are also useful to consider for full termers.  The study found that up to 40% of “premies” are treated with various medications to address reflux and 3/4 of those patients are started as outpatients: in other words based only on empiric examination without more specific evaluation and testing. This trend is very troubling.  These are not benign medicines.  The study states that “although there remains a role for these medications in documented reflux diseases, empirical treatment of infants is not recommended.”  Complications like pneumonia, gastroenteritis, clostridium dificile (serious GI) infection, alteration in gut microflora, and fractures (due to impaired digestion) are documented.

And what are meds accomplishing?  Not too much, according to NASPGHAN, the pediatric gastroenterology society:

  • Crying–“The available evidence does not support any empiric trial of acid suppression in infants with unexplained crying, irritability, or sleep disturbance.”
  • Apnea/SIDS–“The available evidence suggests that in the vast majority of infants, GER is not related to pathologic apnea.  Pharmacotherapy has not been shown to be effective.  The occurrence diminishes significantly  with age and without therapy in most cases, suggesting that no anti-reflux therapy is needed.”
  • Asthma/wheezing–“There is no strong evidence to support empiric therapy in unselected patients with wheezing and asthma.”
  • Poor growth–the guidelines suggest that rather than empiric trial of acid reflux medication, careful evaluation for other chronic causes of growth failure, and then close outpatient monitoring of calorie intake and weight gain; trial non-milk and then specialized hypoallergenic formulas, and for severe and persistent cases inpatient observation and testing, and tube feeding may be indicated.

So what CAN we do for that crying, barfing baby?

  1. Avoid tobacco smoke exposure.
  2. Thickened feeding–1 tsp cereal:2 oz formula.  Perhaps adjust nipple hole size/tightness of nipple on bottle for adequate milk flow/swallowing.
  3. Smaller volume/more frequent feeding with frequent burping.
  4. Formula change: a trial of milk free or hypoallergenic formulas is often wise.  I recommend a trial of minimum 3-4 days(unless a violent reaction).  Only striking change, I feel, is meaningful. “Slight” improvement is usually “observer bias”–science talk for “wishful thinking.”
  5. Positioning–lying on child’s back is bad, even with head elevated.  After feeding keep baby upright for 1/2 hour or lie on right side x 1 hour then on left side afterward.
  6. To the extent that medications may be tried, NASPGHAN guidelines suggest a short 2 week trial only to break the cycle.  In the recent premie study, 43% of infants started before age 6 mo were still on medications after their 1st birthday (not if I can help it!)

The above conservative therapy shows significant improvement in >3/4 of patients and  complete resolution in 1/4.  As previously stated, in most infants it normally resolves within a few months anyway.  So, as in so many other situations, for me here mostly “just say no” to drugs.

Send along questions/suggestions.  Thanks for following.

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