Just last week I published an article on gastroesophageal reflux (often abbreviated “GERD”). I wrote “All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.”

Well, I think I missed the boat on this one. A new Canadian study in adults has shown that long-term use of acid-blocking medications can lead to decreased bone mineralization, presumably by interfering with calcium absorption in the gut. It’s difficult to know how “long term” use has to be to lead to problems, but we do know that children need to be able to absorb proportionally more calcium than adults to grow good bones. I was unable to find any studies looking for this effect in children, but there’s no reason to think that children won’t be affected by these medications in a similar way.

GERD medications, then, should still be considered safe for short-term use, probably on the order of a few months. For longer-term use, patients and doctors should think critically about whether the medications really need to be continued. If they do, parents need to ensure that the child is getting enough calcium, vitamin D, and exercise. If a child really has to stay on these medications very long term, for a few years or more, than I would do a bone mineral density study to see if calcium absorption is adequate.

This story reinforces an important lesson: all medications have side effects, and none should be considered “completely safe.” In fact, you can bet that any medicinal product that promises to be completely safe probably has no biologic activity at all. If a medicine, herb, or any alternative-medicine intervention has a genuine positive benefit, there is going to be a potential for side effects that needs to be kept in mind.

A post from EH: “Recently I have been hearing about a link between dairy protein and diseases such as cancer and diabetes. What are your thoughts on this and can a vegan diet be healthy for small children?”

I haven’t seen any good data that supports a strong link between dairy products and either cancer or diabetes. The press likes to report things as if there is a single cause—a “smoking gun”—that’s the root cause of these problems, it’s unlikely that either disease is the result of one kind of food or exposure. As with many health conditions, they’re complex, poorly understood, and difficult to sum up for a 45 second sound bite on the news.

Nonetheless, this is the Pediatric Insider site, and I’m going to take a stab at it: in 45 seconds, what are the best ways to prevent cancer and diabetes?

Cancer is primarily a disease of aging—in fact, if you live long enough, you will eventually get cancer (for men, prostate; for women, breast: these cancers are almost invariably found in autopsies of people who die past 100 years of age.) So a very effective way to avoid cancer is to die of something else first. If that’s not your cup of tea, try these other ideas:

• Don’t smoke, and avoid environmental smoke exposure.
• Avoid excessive sunlight—but get enough vitamin D.
• Eat a diet rich in plants and low in animal products.
• Vaccinate to prevent cancer of the liver (a consequence of hepatitis B) and cervical cancer.
• Limit alcohol intake.
• Maintain a healthy weight.
• Be mindful if cancer runs in your family, and get screened appropriately to catch cancer early.

Diabetes comes in two varieties, though at times the distinction between the two is unclear. In general, though, type I diabetes is a disease of youth, and no intervention has been effective at preventing it (many ideas have been studied; none have really panned out.) Type II diabetes is far more common, and is in general a disease of adulthood. To prevent it:

• Eat a diet rich in plants and low in animal products.
• Maintain a healthy weight.
• Exercise regularly.

Notice how diet and weight control are on both lists? So, though I can’t say that dairy protein is a specific cause of either cancer or diabetes, a healthful diet needs to include more plant-based foods, and should not contain as much high-calorie, high-fat animal products. Dairy isn’t something that needs to be avoided completely, but should be consumed in moderation as part of a child’s diet.

EH asked if a vegan diet can be healthy for small children. Many vegetarians consider call themselves “lacto-ovo,” meaning they consume dairy products and eggs. Lacto-ovos can get plenty of protein and vitamins and iron from these sources, and it is not difficult to ensure that children on a lacto-ovo vegetarian diet get all of the nutrition they need. Strict vegans do not consume animal products of any kind, and it is difficult especially for children to get enough protein, calories, and micronutrients (especially iron, vitamin D, calcium, and vitamin B12) on a strict vegan diet. Families who wish to raise their children on a vegan diet should consult with a dietician with experience in this area to ensure that everyone in the family gets the nutrition they need.

A vegetarian diet may not be for everyone, but adjusting the family diet to include more plants and fewer animal sources can be a healthy way to decrease your child’s risk of cancer and diabetes.

Edit: Can you believe it, just a few hours after I published this, I found a study reviewing the evidence for the use of vitamin D supplementation to prevent type 1 diabetes! It looks like some good evidence, though the effect isn’t strong it is probably real. So: you still need to avoid sunburns, but getting enough vitamin D via supplementation or sunlight can help you and your children prevent cancer and diabetes.  Cool.

Allison asked, “My 4 year old was just diagnosed by an ENT (via rigid scope) with reflux and needs Prevacid to control it (Prilosec didn’t help). Otherwise, his voice is quite hoarse. If not for the hoarse voice, we would never have known he had it. Why would a 4 year old have reflux and is it something we should be seeing a GI doctor for?”

Reflux is both one of the most over-diagnosed and one of the most under-diagnosed conditions in pediatrics. That’s right: the same disease that’s diagnosed far too often in some children is at other times very sneaky and easy to overlook.

Gastroesophageal reflux (often abbreviated “GER”) occurs when stomach contents, including acid, come up from the stomach into the esophagus. Everyone has this at least every once in a while. If it happens frequently or severely, the stomach contents can damage tissues in the esophagus and upwards. This is called “gastroesophageal reflux disease”, or “GERD.”

GERD is very commonly over-diagnosed, especially in babies. Many babies are fussy at times, and many babies spit up, so perhaps it’s understandable that so many of them are diagnosed with GERD and put on medication. Over-medicating for GERD is especially rampant in NICUs, where tiny preemies often have little blips on their monitors that are blamed on GERD with very little evidence that the therapy is really helping anything. Good, careful studies of babies on GERD medications have shown that most of these babies don’t have GERD at all. GERD medicines are also commonly prescribed as a first-line “let’s-try-something” medication for any child with abdominal pain.

In other circumstances, GERD can easily be overlooked. Though the common symptoms of regurgitation and heartburn are easy to appreciate, GERD can be the root cause of many, more subtle things: trouble sleeping at night, recurrent ear or sinus infections, a hoarse voice, teeth problems, flare-ups of asthma, or other breathing problems. In these children with less-obvious GERD, the diagnosis is often delayed or overlooked completely.

Why would your 4 year old have reflux? Usually, there is no specific cause. We think that the esophageal sphincter that’s supposed to keep stomach contents down might be too loose, or perhaps that the stomach isn’t emptying quickly enough. Sometimes GERD runs in families. It can be made worse by some medicines and food (especially caffeine). Rarely, GERD can be part of an anatomical problem, or can be a manifestation some other esophageal disease (such as eosinophilic esophagitis, which can seem quite similar to GERD but may require different treatment.)

The treatment of GERD includes some lifestyle changes. Kids should eat more slowly, chewing their food well and drinking water during the meal. Vigorous physical activity should be avoided after a meal, and people with GERD shouldn’t lay down immediately after eating.

Medication for GERD includes older antacids like Tums or Mylanta, which will provide relief. The next-generation of reflux medications includes Zantac, Tagamet, and Pepcid, which partially block stomach-acid secretion. The most recent medicines for GERD are also the most effective. These include Prevacid and Prilosec, which completely block the production of stomach acid. All of these medicines work by reducing stomach acid so refluxed material doesn’t damage the esophagus—but none of them actually stop the reflux of material up from the stomach. All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.

Most GERD is easy to treat with safe medications, and if the diagnosis is straightforward and treatment is effective it isn’t necessary to see a GI specialist. But if ordinary therapy doesn’t work, or the diagnosis is in question, a GI specialist should be involved.