Frequent spitting up, irritability, and unexplained crying in infants can be very distressing to parents. Paediatricians often prescribe acid-suppressing drugs for these symptoms in an effort to treat infants for gastroesophageal reflux disease (GERD); however, GERD is an uncommon cause of these symptoms in otherwise thriving infants.
In a soon to be published commentary in The Journal of Paediatrics, Eric Hassall, MBChB, FRCPC, FACG, cautions against the over-diagnosis of GERD and over-prescription of acid-suppressing drugs in infants. Dr Hassall is affiliated with the Department of Paediatrics at the University of British Columbia, Vancouver, Canada, is currently Staff Gastroenterologist at Sutter Pacific Medical Foundation in San Francisco, California, and is an advisor to the US Food and Drug Administration (FDA). Although the FDA has only approved the use of acid-suppressing drugs, such as proton pump inhibitors (PPIs), in children over the age of one year, the use of PPIs in infants less than 12 months old has greatly increased in the last decade.
Dr Hassall notes that most “reflux” in infants is not acidic because stomach contents have been buffered by frequent feedings. “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,” he states. 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 frequently prescribed for symptoms that are not GERD.
Dr Hassall emphasises that throwing up in otherwise healthy infants is normal and resolves with time. Irritability or unexplained crying, with or without spitting up, is often a normal developmental phenomenon, especially in infants 2-5 months old. Although some infants are unable to self-calm, this also improves with maturation and age.
“We are medicalising normality,” Dr Hassall asserts, “In most infants, these symptoms are ‘life,’ not a disease, and do not warrant treatment with drugs, which can have significant adverse effects.” He explains that gastric acid is an early line of defence against infection and is important for nutrition; by prescribing acid-suppressing medications to infants without GERD, paediatricians are putting their patients at a higher risk for infections like pneumonia and gastroenteritis. The use of PPIs in infants can also lead to abnormalities in the levels of essential minerals and vitamins, such as magnesium, calcium, and vitamin B12.