Reflux and babies: Ineffective treatment of a non-disease?
© 2016 Roy Benaroch, MD
Heather wrote in:
As a postpartum doula for the last 12 years I have seen something in the last couple of years that I would love your insight on. At least 30-40% of all the babies I care for now have reflux/GERD diagnosed. Roughly 25-30% are on daily meds for this. Parents go to the DR to get some sort of help for fussy babies and take home a prescription for GERD. Reminds me of when my kids were little and we got RX for antibiotics for so many things.
Heather’s right. Reflex (or GERD, gastroesophageal reflux disease) has emerged as a modern boogeyman, blamed for all sorts of symptoms in babies. The bottom line: most babies thought to have GERD don’t have it, and even among babies who do have GERD the medications used to treat it don’t seem to work.
Some background: “gastroesophageal reflux”, abbreviated GER, is the involuntary expulsion of stomach contents up into the esophagus. Stuff comes back up. All babies, and this is no surprise to parents, spit up, and most of them are perfectly happy to do it. Those “happy spitters” are easy to identify – they have no symptoms at all, no fussiness, they’re gaining weight, everyone is comfortable – and there’s really no controversy that these babies with “GER” need no treatment.
But there’s another abbreviation, GERD, for “gastroesophageal reflux DISEASE”, and that’s when things get murky. GERD = GER + D, or reflux that’s causing symptoms or problems. We’ve thought, for instance, that reflux could cause babies to be in pain. That makes sense, because many adults experience heartburn pain when they reflux. Though babies have less stomach acid than adults, they have some, and you’d think at least some of them might develop pain and inflammation in the esophagus from acid splashing up there. There are other symptoms, too, that have been blamed on GERD, like breathing problems or poor growth. And these do happen – GERD is a real thing.
Problem is, when it comes down to objective testing, it’s very difficult to tell whether GER is really causing the D in an individual patient. Yes, Junior is spitting – we can see that, it’s on the floor and all over dad’s shirt. And yes, Junior is fussy. But does one really cause the other? Does treating GER really help the symptoms we’re blaming on the reflux?
A study from the April, 2016 edition of the Journal of Pediatric Gastroenterology and Nutrition tried to help figure this out. They used a state-of-the-art diagnostic tool, a multichannel intraluminal impedance study, on 58 infants suspected of having GERD. Most of these babies had irritability as their main symptom. Of the 58 babies, only 10% ended up having an abnormal study – only 10% actually had reflux. And, among the babies who had episodes of irritability during the study itself, only about 20% had reflux during their symptoms. Reflux, when measured objectively, is uncommon even in babies who have symptoms we think of as reflux-related. And even during the symptoms, reflux usually isn’t occurring.
Do GERD medications, which primarily work by blocking acid secretion, even work in babies? The evidence, as reviewed by Jay Hochman in his pediatric GI blog, says “no.”
It’s a conundrum. My gut feeling (ha!) is that GERD really does occur in some babies – but not often, and certainly not in most babies evaluated for fussiness. And if there isn’t GERD in the first place, of course the medicines for GERD aren’t going to help. There’s a strong placebo response rate in GERD studies of infants, so maybe to some degree an expectation of relief helps parents deal better with their babies’ fussiness. Or maybe the meds do work in the real cases of GERD, if diagnosed correctly in the first place. It’s just hard to separate all of this out, because the symptoms are so common. And those little babies don’t talk yet, so we don’t really know if they’re in pain, or where the pain is coming from.
Babies with excessive fussiness need a medical evaluation. Some, but not most, will have a specific medical explanation for their crying, and sometimes treatment helps. Many have more of a temperamental or developmental fussiness, and need to be held, and need reassured parents with backup support and a few good nights of rest to catch their breath. Medications aren’t always – or even usually – the answer.