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Monday, February 13, 2012

The cure for normal infancy?

Just when I think I'm running out of less-is-more examples in pediatric healthcare, here comes a review of acid-blocking medications and their use in newborns diagnosed with "acid reflux."

What would cause one to consider the diagnosis of acid reflux (also known as gastroesophageal reflux disease, or GERD) in a newborn?  This entity is known to cause a variety of symptoms, from strange arching postures, cough and wheeze to apnea with blue spells.  But mostly, GERD is diagnosed in infants with spitting up, excessive fussiness and crying.  Hmmm.  How, you might ask, does one differentiate this condition from, well, normal infant behavior? 

As it turns out, not easily.  A lab test? There isn't one.  What about imaging?  Well, a barium swallow could help, but there's radiation and the study is hard to interpret.  So most pediatricians go with "empiric therapy" which is Greek for "let's do an experiment and see what happens."  The rationale for this stratagem is that acid blocking medications are basically harmless.

Except for the following.  As noted by Dr. Eric Hassall recently in the Journal of Pediatrics, these medications have now been linked to increase risks for pneumonia, candidemia, necrotising enterocolitis and C. difficile infection of the intestinal tract.  These are in addition to risks already documented in older patients including osteoporosis and impaired absorption of calcium and magnesium, minerals critical to health.  As it turns out, stomach acid is there for a reason, and eliminating it comes at a larger biological cost than most of us imagined.

I have been curious about this whole neonatal "reflux" thing for quite a while.  For one thing, we seem to have overlooked it for several decades without apparent harm.  It is also interesting that the diagnosis of "infant colic" has disappeared over the same time period that the incidence of newborn reflux has exploded.  Something, I dare say, is rotten in Denmark.  But maybe not so surprising.  How is colic different from reflux?  Simple.  One is treated with a car ride, the other with medication.  And if you wait a few weeks, both most often go away.   

By the way, I DO recommend pharmacotherapy for this condition:  my favorite regimen includes 4 oz of a chilled Muscadet per orum for each parent.

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