Infants who are frequently spitting up, irritable, and cry for unknown reasons can be extremely worrying for parents. The infants are often prescribed with acid-suppressing drugs by their pediatricians in an attempt to treat them for gastroesophageal reflux disease (GERD) but in otherwise thriving infants GERD is not a common cause of these symptoms. Eric Hassall, MBChB, FRCPC, FACG, warns against the over-diagnosis of GERD and over-prescription of these drugs in infants, in a Commentary that is soon to be published in The Journal of Pediatrics.
Dr. Hassall is affiliated with the Department of Pediatrics at the University of British Columbia, Vancouver, Canada, is at present Staff Gastroenterologist at Sutter Pacific Medical Foundation in San Francisco, California, and an advisor to the U.S. Food and Drug Administration (FDA). The number of infants younger than 12 months using proton pump inhibitors (PPIs) - an acid-suppressing drug - has increased significantly in the last 10 years, even though the FDA has only approved the use of acid-Suppressing drugs, such as PPIs to children over 1 years old.
According to Dr. Hassall the majority of 'reflux' in infants is not acidic as frequent feedings have buffered the stomach contents. Hassall explains:
"However, in the absence of better information and physician guidance and fed by advertising and misinformation on the Internet, distressed parents take their concerns to doctors, who very frequently comply and prescribe acid-suppressing medications for symptoms and signs that, in most cases, are not GERD."
It has been revealed in investigations that PPIs are no more effective than placebos for the majority of infants with these symptoms, which might be due to drugs being frequently prescribed for symptoms that are not GERD. Dr. Hassall stresses that it is common for otherwise healthy infants to spit up and it resolves with time. In addition he explains that unexplained crying or irritability, with or without spitting up, is usually a normal part of development, particularly in infants aged between 2-5 months. Even though some infants can't self-calm, this improves as the infant matures.
Dr. Hassall cites: "We are medicalizing normality. In most infants, these symptoms are 'life' not a disease, and do not warrant treatment with drugs, which can have significant adverse effects." Gastric acid plays an important role by defending against infections early, and is vital for nutrition. Pediatricians who prescribe these drugs to infants without GERD are putting them at a higher risk for developing infections such as gastroenteritis and pneumonia. In addition drugs like PPIs can lead to abnormal levels of essential vitamins and minerals, such as calcium, vitamin B12 and magnesium.
Dr. Hassall asks other pediatricians to first look into non-pharmacological methods, such as diet change in mothers who are breastfeeding or hypoallergenic formulas for infants who are bottle-fed. Hassall recommends that if these methods fail or if severe symptoms are observed and it suspected that the child has GERD, treatment with an acid-suppressing drug should be started for a time-limited period of two weeks. However, Dr. Hassall explains:
"In most cases, it is not the spitting up that should be treated. The real issue is the unexplained crying, which causes real and considerable distress and concern for parents. It is important for pediatricians to acknowledge their concerns, explain the spectrum of normal infant behavior, discuss the range of measures available, start implementation, and be available for follow-up."
Written by Grace Rattue