Why are doctors giving babies heartburn pills meant for adults
00:54 GMT, 11 December 2012
Join any mother-and-baby group or search any online baby forum and at least one parent will be discussing reflux.
Around 50 per cent of babies under three months have it to some extent.
It’s caused by a weakness of the valve at the top of the stomach that normally keeps food in.
Sarah Crompton with her children (from left) Theo, Archie and Sasha. All the children have suffered from reflux
In babies this valve can be loose, so their feed and gastric acid is able to escape back up the oesophagus, causing pain.
‘The sphincter at the junction between the top of the stomach and the oesophagus becomes stronger during the first year of a child’s life, which means reflux becomes less and less of an issue after the age of one,’ explains Dr Mike Thomson, a paediatric gastroenterologist at Sheffield Children’s Hospital and The Portland Hospital, London.
Babies with reflux typically ‘posset’ (bring up their feed) and become fractious after feeding or when they lie down.
The crying can last hours, even all day.
Some, but not all, will be sick, so some babies with reflux fail to thrive as they should.
In rare cases, the reflux gets into the lungs and causes coughing and spluttering.
For mild cases, simply giving smaller feeds or keeping them upright after feeds is enough to help.
However, for more severe cases medication is needed — and, increasingly, that means drugs called proton pump inhibitors (PPIs), such as omeprazole, which dramatically reduce the amount of acid produced in the stomach.
Proton pump inhibitors are the most common medicines used for treating adult heartburn or ulcers.
Recently, concerns have been raised over the use of these powerful drugs in adults.
Experts warn that stomach acid has a vital, protective role in the body and that taking the drugs long term is linked to infections as well as a deficiency in some minerals and vitamins (too little stomach acid makes it harder for certain nutrients to be absorbed from food).
Five months ago, doctors tried to put Sarah's youngest child, Sasha, then seven months, on omeprazole
The patient and doctor have to, therefore, weigh up the benefits versus the risks.
But in children, there is a question mark over whether there are any benefits at all.
Indeed, research suggests that proton pump inhibitors do very little to help reflux in babies and children.
Some experts believe this is because the real problem is the baby’s anatomy, or an allergy (and not stomach acid).
Reflux is often triggered by an allergy — normally to cow’s milk — which seems to cause irritation and swelling in the nerves and muscles around the sphincter.
In the past few years, two reviews of the evidence for proton pump inhibitors found they’re not an effective treatment for common infant reflux symptoms.
Dr Eric Hassall, a U.S. paediatric gastroenterologist, is a leading critic of the use of proton pump inhibitors in children.
Last year, in an article for the Journal of Pediatrics, he argued that the drugs are being prescribed far to regularly.
He claims that too often, a diagnosis of reflux is given when, in fact, in most infants ‘these symptoms are life, not a disease, and do not warrant any treatment with drugs’.
Furthermore, Dr Hassall says for young babies, stomach acid is a key defence while their immune systems mature.
Reduce the acid, he says, and you make these children more vulnerable to infections.
This is because stomach acid acts like a disinfectant. U.S. research has shown that adults taking proton pump inhibitors have a higher risk of the superbug C.difficile.
Patients on the drugs also have a raised risk of pneumonia.
The link between proton pump inhibitors and infection in children is not clear (there’s been just one small study, involving older children).
However, many children don’t need the drugs in the first place, says Dr Thomson, because stomach acid is not the real problem.
In the end, Sasha improved after being given ranitidine. 'When she went on to this drug, she became a happy child,' said Sarah
‘The evidence that stomach acid is the cause of reflux in infants is very, very limited,’ he says.
‘Normally their stomach acid is mixed with a milky feed, which will largely neutralise the acid.
'It is more likely that their anatomy is the cause.’
Or it could be an allergy, as Sarah Crompton discovered.
Her son Theo, now two, suffered from mild reflux from birth, but it worsened after he suffered an allergic reaction to fish at 12 months old.
He would scream after each feed and writhe around for hours on end.
‘It was quite frightening to witness how much pain he was in,’ says Sarah, 41, who is married to 39-year-old Trevor, a sales director, and has two other children, Archie, five, and Sasha, 13 months.
The couple took Theo to a paediatrician and he suggested omeprazole, mixed with water and syringed into his mouth.
However, within days, Theo was bleeding from his gums and lips.
‘He started being sick again so, actually, it made things worse,’ adds Sarah, from Minety in Wiltshire.
She immediately took Theo off the medication and dosed him with Infant Gaviscon instead, with limited effect.
But in September last year, nine months after this episode, her elder son Archie who had also suffered from reflux as a baby, complained to his mum about the ‘sick’ coming up his throat.
He also developed a barking cough at night — another symptom of reflux.
He, too, was put on omeprazole.
‘Within days he was covered with massive red, itchy welts all over his body, which was absolutely horrid,’ says Sarah.
‘The paediatrician told us to stop giving it to him immediately. He had to have a steroid to help bring the welts down.
'The rash was that bad they were worried about him developing a skin infection.’
Recently concerns have been raised over the use of powerful drugs – such as omeprazole – in adults
Then, five months ago, doctors tried to put Sarah’s youngest child, Sasha, then seven months, on omeprazole.
Sasha suffered from reflux even worse than her brothers.
‘She would be contorted in agony, screaming and writhing,’ says Sarah.
‘I could feed her at 10pm and she’d still be screaming at 3am.
‘The only way to settle her was to carry her round upright in the sling, which I did practically day and night.
'I also used to have to sleep with her lying propped up against me and was unable to put her down on her back for more than a few minutes.
‘But there was no way I was going to let her go on that drug after what it did to her brothers’ — especially as Sarah learned that her children’s reflux is likely linked to allergies.
While such skin reactions to proton pump inhibitors are a known side-effect, they are rare.
Even so, PPIs for youngsters are generally being prescribed too readily, suggests Steve Tomlin, a consultant pharmacist and Royal Pharmaceutical Society spokesperson on medicines for children.
‘These drugs are viewed as relatively safe, so it has become common practice to treat symptoms of reflux with proton pump inhibitors,’ he says.
‘However, I would not think it necessary to go down that road unless the reflux was causing significant symptoms.
‘There are other steps that can be tried first, such as posture — elevating a baby’s head when it lies down, — giving smaller feeds more often, giving feed thickeners to stop the food from coming back up and antacids.
'But I think these steps are being jumped through much quicker than they used to be.’
In some very specific, severe cases, proton pump inhibitors such as lanzoprazole are of benefit, adds Dr Thomson.
‘But my experience of its usefulness is anecdotal and I would only suggest it was used sparingly.’
In the end, Sasha improved after being given ranitidine.
This works in a similar way to PPIs — but while PPIs totally shut down acid production, ranitidine just reduces it.
‘When she went on to this drug, she became a happy child,’ says Sarah.
But the drug costs 200 a month and her GP surgery wanted to put Sasha on the cheaper omeprazole.
‘Our paediatrician told them she shouldn’t have this medication due to the reaction of her brothers and that she did not need to be on such a strong medication,’ says Sarah.
‘They arranged for me to see another paediatrician, who also agreed she should not be on ompeprazole.’
Sarah has since managed to wean Sasha off even ranitidine.
‘She is drug-free and a very settled baby now,’ says Sarah.
‘She still suffers from allergies, so we have to avoid certain foods.
'But keeping on top of that means she doesn’t suffer from reflux.
'She didn’t need a proton pump inhibitor to achieve that.’