Reflux and babies: Ineffective treatment of a non-disease?

The Pediatric Insider

© 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.

Little. Purple. Different?

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3 Comments on “Reflux and babies: Ineffective treatment of a non-disease?”


  1. Thanks for this post, and the link to the study! As a certified Happiest Baby on the Block educator, I get asked about reflux all the time. So many parents don’t want to believe that they have a fussy baby, not a GERD sufferer. Solving newborn fussiness is what I do!
    There are still plenty of parents who still want that antibiotic when their child has a virus, and lots of parents that want the fussiness to stop with a pill. They don’t want to hear about the adverse affects of either strategy. My take? By administering medication they can feel that they have taken an action that has an authority’s approval. Their stress is reduced, even when their child’s distress isn’t reduced.

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  2. Thank you for this response. The thing that bothers me about this is so we have any information on the long term side effects of babies taking this medication?
    Take Care,
    Heather

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  3. Tern Says:

    Ok, here’s my worthless anecdote. My son was 2.5 weeks old when I noticed he was getting very squirmy after feeds. By 4 weeks this developed into screaming with vocal hoarseness after every feed. It was truly awful. Because our maternal&child health nurse had said it was ok, I didn’t do anything straight away, but as his distress grew worse to the point that we had not slept in two days, I took him to a GP who suggested silent reflux. I knew it was a bit of a sketchy diagnosis, but we had to try something, so we had a go with some thickened breast milk at each feed. The first time he had a few ml, he just went straight to sleep without even having the feed. It didn’t make much difference when added to the full feed, so within a day or two, as the GP predicted, we got the script for ranitidine filled. The screaming stopped completely within a few days, and only threatened to recur when he grew out of his dose a couple of weeks later. A couple of months later, the vomiting became apparent, but he stayed on ranitidine (and with appropriate increase in dose as per his weight gain) and we had no trouble with the distress and screaming until I gathered the courage to stop it around 8 months. I’m sure you could dismiss this as easily as someone swearing that cranio-sacral therapy/chiro/[insert other form of quackery] fixed their baby’s GORD, but i will forever be grateful to big pharma for ranitidine!

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