Reflux medication

Should I give my baby prescription medication for reflux?

Babies diagnosed with gastroesophageal reflux disease, or GERD, may be prescribed drugs that reduce acid in the stomach. These medications have risks and limited benefits. They do decrease the amount of acid, but they may not change the baby’s behaviour. Reported side effects include an overgrowth of harmful bacteria in the gut and an increased risk of allergies and infection. They have been linked to an increased risk of childhood obesity and broken bones. Acid-suppressing medication is effective in the first two to four weeks. If not, it may be wise to review the diagnosis and the treatment.

A) Describing acid-suppressing medication

As the popularity of the gastroesophageal reflux disease (GERD) diagnosis increased from the mid-1990ies, so too did the use of acid-suppressing medications to treat it (Illueca 2014). 

There are two groups of such medication: 

  1. Histamine 2 receptor blockers (histamine 2 receptor antagonists, or H2RAs)
  2. Proton pump inhibitors (PPIs)

While these medications decrease the amount of acid in the stomach and can help with the healing of an irritated swallowing tube, they do not stop the process of reflux.

Acid-suppressing medication should not be given to otherwise healthy babies to treat crying or spitting.

B) Side-effects of acid-suppressing medication

Concerns remain about the safety and effectiveness of these medications (De Bruyne 2018; Hassall 2012; Hua 2014; Scarpignato 2016; Slaughter 2016; Smith 2013; Vandenplas 2009).

1) The role of acid in the stomach

Normally the stomach is very acidic. The acid:

  1. Starts breaking down protein.
  2. Activates certain hormones (cytokines) (Nakamura 2009).
  3. Activates the hormone pepsin, an enzyme that breaks down protein.
  4. Signals the stomach to allow food to pass into the bowel.
  5. Signals the pancreas to release enzymes into the bowel to help with food digestion.
  6. Prevents harmful microbes and prevents them from passing on to the bowel.

Acid-suppressing medications reduce the amount of acid, interfering with these processes.

2) The risk of allergic disease

A study (Mitre 2018) of nearly 800,000 children showed a marked increase in the risk of several allergic diseases:

Table: Increased Risk of Disease in Children by 4½ Years of Age When Given Acid-Suppressing Medication (Mitre 2018)

Illness

 H2RAs

PPIs

Anaphylaxis 

1.51

1.45

Allergies to medication

1.70

1.84

Food allergies

2.18

2.59

Hay fever

1.50

1.44

Asthma

1.25

1.41

Anaphylaxis is a severe, potentially life-threatening allergic reaction. This table shows that babies who had taken acid-suppressing medication had about 1.5 times the normal incidence of anaphylaxis. 

3) The risk of infection

Acid-suppressing medication has been shown to increase the risk of a baby getting:

  • A particular gut infection (C. difficile) by 4.5 times (Brown 2015)
  • Other stomach infections (Canani 2006; Chung 2013)
  • Pneumonia (Canani 2006; Chung 2013)

4) The risks of obesity  

The use of acid-suppressing medication increases the risk of childhood obesity, especially if used for long periods or given with antibiotics (Stark 2019).

5) The risks to premature babies  

Premature babies given acid-suppressing medication have an increased risk of illnesses including (Chung 2013; More 2013; Patil 2017):

C) Proton pump inhibitors

1) Describing PPIs

PPIs are the newer and more powerful acid-suppressing medications. They work by blocking the last step in acid production.

 Examples of PPIs include:

  • Omeprazole
  • Lansoprazole
  • Dexlansoprazole
  • Esomeprazole
  • Pantoprazole
  • Rabeprazole

PPIs are used to treat babies with swallowing tubes damaged by stomach acid. They are also used to treat the typical symptoms of GERD but their effectiveness for this is uncertain (Gonzalez Ayerbe 2019; Rosen 2018).

2) Side effects of PPIs

A study (Malchodi 2019) of 850,000 children up to 14 years of age showed that receiving PPIs in the first year of life increased the risk of having a broken bone by 23%. This increased to 31% when combined with an H2RA.

PPIs have been shown to reduce the types of bacteria and increase the numbers of harmful bacteria in the microbiomes of the gut, lung, mouth, and throat (Castellani 2017; Rosen 2015; Stark 2016).

One study (Belei 2018) reported that 55% of babies tested had an overgrowth of harmful gut bacteria after 12 weeks of using PPIs compared to 5% of those who did not receive them. Other studies have reported similar effects (Yadlapati 2018).

D) Histamine 2 receptor antagonists

H2RAs are the older group of acid-suppressing medication. Histamine is a chemical used by the stomach to stimulate the production of acid. Production begins when a molecule of histamine connects with a histamine receptor. Histamine works like a key and the receptor is the lock; once the lock is opened, acid production begins. H2RAs block the lock and thereby reduce acid production.

1) Describing H2RAs

Examples of H2RAs are:

  • Cimetidine
  • Famotidine
  • Nizatidine
  • Ranitidine

It is uncertain whether the use of H2RAs reduces crying, distress, spitting, vomiting, or heartburn or improves damage of the swallowing tube in children with GERD compared with placebo (sugar pills) (Rosen 2018).  

H2RAs are used to treat swallowing tubes damaged by stomach acid if PPIs are not available or are unsafe for the baby (Rosen 2018). Unlike PPIs, H2RAs tend to lose their effectiveness as the body can get used to them. H2RAs are also less effective than PPIs, making the latter the preferred medication (Gonzalez Ayerbe 2019).

2) Side effects of H2RAs

In some infants, H2RA therapy causes irritability, head banging, headache, and sleepiness (VandenPlas 2009). One particular H2RA (cimetidine) has been shown to increase the risk of liver disease and growth of breast tissue (VandenPlas 2009).

In 2020, the U.S. food and Drug Administration recalled all products that contain ranitidine over concerns of contamination with N-Nitrosodimethylamine (NDMA), a possible carcinogen (FDA 2020).

E) Other medication

Various other drugs either do not have enough evidence supporting their use or have serious side effects. These include:

Cisapride was introduced and used in the 1990s as a treatment for GERD. It was withdrawn from the market in 2000 because of the increased risk of heart rhythm abnormalities (Quigley 2011; Shaoul 2002; Vandenplas 1999).

F) Deciding whether to use acid-suppressing medication

In 2018, the Joint Committees of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) stated (Rosen 2018):

 “Given the mounting data in adults questioning the safety of these medications in multiple organ systems, these medications should be prescribed only when there is a clear diagnosis of GERD and, whenever possible, the lowest doses should be prescribed for the shortest length of time possible”.

Others  have concerns about using acid-suppressing medication on premature babies. The Committee on Fetus and Newborn of the American Academy of Pediatrics states (Eichenwald 2018):

“… a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in  preterm infants.”

Acid-suppressing medications have been shown to have limited benefits and many possible short- and long-term risks. If your baby has been diagnosed with GERD and starts this medication, you should notice improvement in their condition in two to four weeks (Rosen 2018). If not, you may wish to reconsider the diagnosis and return to your health-care providers.

References

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