Gastroesophageal reflux (GER) and the more serious gastroesophageal reflux disease (GERD) are commonly treated with proton pump inhibitors (PPI). A PPI is a medication that reduces the production of acid in the digestive tract by blocking the enzyme in the stomach that produces acid. PPIs include Nexium and Prilosec. But is this really the best course of action for your baby?
Making a diagnosis
For all the discomfort they cause, neither GER nor GERD are particularly easy to identify. After all, points out Johannesburg paediatrician Dr Enrico Maraschin, the most common sign of the pain caused by these conditions is crying – and what baby doesn’t cry?
In truth, though, the complexity of both GER and GERD is only now coming to be understood. Dr Maraschin notes that, 28 years ago, when his own baby displayed all the signs of reflux, his suggestion that his son be treated with medication to suppress stomach acids raised several eyebrows.
The existence of GER and GERD in babies has become more accepted, but so many questions remain. Why are some babies troubled only to the extent that they need a change of clothes more frequently than their peers, while others struggle to draw breath, for example. Add in the long list of alternatives that may cause the same symptoms (such as vomiting or frequent waking), and it’s clear why doctors find this a tricky condition.
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It’s precisely because the condition is so difficult to pinpoint that PPIs, although effective, should not be considered a first-line defense.
Fortunately, says Dr Maraschin, as understanding of reflux evolves, so do treatments – and increasingly, it’s clear that even small measures can make a significant difference. For example, many parents have found that it helps to increase the frequency of feeds, while reducing the volume – in other words, feed less, but more often.
Thickening your baby’s feed is another option which often proves successful. Adding starch thickens the feed thereby reducing both the volume and frequency of regurgitation and crying. This is obviously easier where babies are formula-fed – all it entails is selecting a formula which has already been mixed with thickener, such as Novalac AR, Nan AR, or in severe cases, Novalac AR Digest.
What about if you’re breastfeeding?
It’s a little more difficult for breastfeeding mothers. Although thickeners are readily available from pharmacies or specialist baby stores, these have to be added once the milk has been expressed – and then there’s the possibility that the mixture will turn to an unpalatable gel, or that your baby simply won’t take to it.
If that’s not working, it might be worth investigating whether your child is having an allergic or intolerant reaction to cow’s milk protein in her milk. Once more, this is an issue that’s a little easier to address if your baby is formula-fed: simply look for a formula where the cow’s milk protein has been broken down to basic units, also known as extensively hydrolysed formula. And if that doesn’t work, choose one that’s based on amino acids.
If, on the other hand, you’re sticking to breastfeeding, it’s worth consulting a dietician who can help you eliminate all sources of cow’s milk protein from your diet. You should start to see positive results after four weeks.
Still struggling? Then, if you live in an area that has access to a range of medical practitioners, you may consider consulting a paediatric gastroenterologist.
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Enter the Proton Pump Inhibitors
If all else has failed, it may be time to consider PPIs. Dr Maraschin notes that although there haven’t been any serious side effects exhibited in children, there are concerns that these medications may bring about an increase in gastrointestinal tract, respiratory tract and urinary tract infections.
Studies in adults also show that there is evidence that PPIs may cause Vitamin B12 deficiency, low magnesium levels, and a risk of bone fractures. “There is no convincing evidence that these risks apply to children, however. Further studies are required to address the question of side effects in children,” Dr Maraschin comments.
The key to successful treatment with PPIs, Dr Maraschin says, lies in using them only when there is a clear diagnosis of GERD. Treatment should be at the lowest possible dose, and used for the shortest possible period. That said, it’s important to stop treatment slowly. An abrupt end to the medication will send your body into acid overdrive, creating a condition called rebound hyperacidity, so that the original symptoms return.
Our understanding of GER and GERD keeps developing, as does our understanding of PPIs. Although these medicines certainly have an important role to play and may be very effective, there are other treatment options that should be considered before the use of PPIs,” Dr Maraschin concludes.