Reflux among babies often a misdiagnosis

Adult medications rarely justified for children who spit up, doctors say

December 13, 2007|By Stephanie Desmon | Stephanie Desmon,SUN REPORTER

As long as there have been babies, there have been babies who spit up.

Now this behavior, long dismissed as something that most infants just do, has evolved into a 21st-century disease. Critics say the condition is widely misdiagnosed and overtreated with unnecessary doses of heartburn medicine developed for adults.

They call it the phenomenon of the "purple pill," a nickname for Nexium - one of many prescription drugs hawked incessantly on the airwaves to treat acid reflux, which itself is a medical term virtually unheard of 20 years ago.

This aggressive marketing, critics say, can persuade parents to demand that their infants get medication they can easily do without - medication that is unlikely to be approved for small children, that could affect developing bones and that might not even work at blocking acid.

"Pediatricians feel absolute pressure to give medications, especially compared to 10 years ago," said Dr. Maria Oliva-Hemker, a pediatric gastroenterologist at the Johns Hopkins Children's Center. "It's so unusual for a baby to be referred to us who's not on an acid blocker. We've kind of created a monster."

To be sure, there is a serious condition that afflicts some children - and adults - called gastroesophageal reflux disease, or GERD. Those babies spit up, too, but they can appear to be in great pain. They might not gain enough weight and struggle to breathe or gag as a result of eating.

These children likely need reflux medication - Zantac, Nexium or Prevacid, among others - to decrease the burning from the acid that is forced into their food pipes and then out their mouths.

But doctor say those youngsters are a distinct minority.

"We are grossly over-prescribing," said Dr. Vikram Khoshoo, a pediatric gastroenterologist at West Jefferson Medical Center in New Orleans.

Normal reflux occurs when stomach contents back up into the esophagus - the food pipe to the stomach - during or after a meal. Spitting up is common in babies: The ring of muscle that connects the esophagus and the stomach, and normally opens to release gas after meals, can be overwhelmed by the volume in a bottle consumed quickly.

More than half of all babies experience reflux in the first three months - some estimates are as high as 80 percent - but most stop spitting up between age 1 and 2.

"It's a laundry issue. You've got to do more clothes," said Khoshoo. "It's not a truly medical issue."

In last month's issue of Pediatrics, Khoshoo and colleagues published a study they began after noticing that the number of infants referred to their practice for excessive spitting up nearly doubled from 1999 to 2007 - and that 90 percent were on medication for it.

The small study showed that most infants they saw for persistent regurgitation had not GERD but normal reflux, another term for plain spitting up.

"In our patients, acid-suppressing drugs were used frequently for reflux symptoms, although no objective diagnosis of GERD was established," the authors wrote. "The persistence of regurgitation despite anti-GERD medications was no surprise because these drugs are unlikely to reduce the frequency of reflux."

Doctors have more conservative measures they can take before shifting to drugs. Parents can thicken infant formula with rice cereal to provide the same number of calories in smaller feedings. They can try different formulas in case an allergy is setting off the vomiting.

The head of the crib can also be raised 30 degrees to promote proper digestion during sleep, and children can be held close to upright just after feeding. Only after parents try these remedies should they consider medication, Khoshoo said.

He said he takes about four infants off reflux medication in his office every day.

"Everyone's sort of skipping the practical stage," said Elizabeth Pulsifer-Anderson, a Frederick woman whose grown children suffered from GERD when they were younger and who runs an advocacy group for the disease. "We just need to remember to try the simple steps before we try the chemical stuff."

The use of prescription drugs to treat children with reflux and GERD has grown significantly over the past five years. More than 2 million youngsters took them in 2006, according to an analysis by Medco Health Solutions, a pharmacy benefits manager spun off from drugmaker Merck & Co.

Medco found that the fastest-growing group of reflux drug users among children was youngsters under age 4 - up 56 percent from 2002 to 2006. A study published in October's Journal of Pediatric Gastroenterology and Nutrition showed that the use of certain reflux medicines in infants less than a year old increased 750 percent between 1999 and 2004.

While some doctors say the drugs are safe, others worry about their long-term effects.

One recent study showed a correlation between hip fractures and extended use of heartburn medications in older people. And most of the medications given to infants have not been tested in young children and are not indicated for their use.

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