Acid reflux drugs called overprescribed in infants

Many infants spit up and cry but it usually doesn’t need to be treated with acid-suppressing drugs, says a pediatrician countering  marketing campaigns.

Acid-suppressing medications such as proton pump inhibitors are often prescribed to infants who frequently spit up, are irritable and cry. But gastroesophageal reflux disease or GERD is not usually the cause of the symptoms in otherwise thriving infants, Dr. Eric Hassall, said in a commentary in Thursday's issue of The Journal of Pediatrics.

"In the absence of better information and physician guidance and fed by advertising and misinformation on the internet, parent blogs have increasingly promoted the 'my-baby-has-acid-reflux-and-needs-drugs' concept," Hassall, a gastroenterologist at Sutter Pacific Medical Foundation in San Francisco, wrote.

"Parents, concerned by their infant’s symptoms of apparent suffering, take their concern to doctors, who very frequently comply and prescribe acid-suppressing medications for symptoms and signs that in most cases are not GERD. GERD-mania is in full cry, so to speak."

In otherwise healthy infants, some 40 per cent to 70 per cent spit up daily, Hassall noted. That's because infants can take in more than they can hold and the overflow can come back up.

In most cases, the spit up isn’t actually acidic since the reflux is buffered by frequent feeds.

Infant symptoms are 'life'

But since rules around direct-to-consumer advertising were relaxed in the U.S. in mid-1990s, marketers have popularized the term "acid reflux" in ads, blurring the lines between physiologic, acid and non-acid forms of reflux, said Hassall, who is also a a gastroenterologist at Sutter Pacific Medical Foundation in San Francisco

Many infants also have unexplained crying or colic, especially in the first three or four months of life. As doctors have less time to take a time-consuming history and discuss dietary and behavioral approaches to evaluate unexplained crying, some physicians take a quicker approach of prescribing, he said.

Studies have shown that PPIs are no better than placebo for most infants with symptoms of spitting up, irritability, or unexplained crying, which may be because the medications are often prescribed for symptoms that are not GERD.

"In most infants, these symptoms are 'life,' not a disease, and do not warrant treatment with drugs,  which can have significant adverse effects."

Potential adverse effects include higher risk of infections like pneumonia and gastroenteritis as well as abnormalities in the levels of essential vitamins and minerals.

Instead of prescribing, Hassall suggested that doctors explain to parents how infants cannot self-calm, and how to help their children to do so.

Tips include:

• Rhythmic rocking and patting two to three times per second in a quiet environment, recognizing that that baby may still resume crying as soon as he or she is put down.
• A car ride does not eliminate pain but stops the crying, which Hassall said "has diagnostic and therapeutic value."

In one study, unexplained crying improved overall in 78 per cent of infants within two weeks with only positional and feeding changes and exclusion from exposure to tobacco smoke.

For a child with likely or proven GERD, the benefits of acid-suppressing drugs in appropriate dose outweigh the risks, and in most cases, also far outweigh the risks of surgery, Hassall concluded.

The author said he received a clinical research grant from AstraZeneca Canada and is a consultant for Takeda Pharmaceuticals.