Oh my G.O.R.D
Why acid suppression for infants with reflux is almost always a mistake
Recently on Twitter1 I responded to a post regarding the prescription of omeprazole for infants with reflux with the following message;
The correct dose is zero because omeprazole is almost never ever indicated for babies
This started a lively conversation with some of my colleagues in general practice including some important questions. Regurgitation of milk is a ubiquitous experience for infants, parents and healthcare providers of children alike, so let’s dive in!
What is reflux?
Reflux is the effortless regurgitation of stomach contents into the oesophagus or beyond (e.g. over your shoulder, lap, face etc). This differentiates it from vomiting, which is accompanied by forceful retching. Reflux is a normal part of infancy, experienced by almost all infants to some degree due to a number of factors:
Infants spend almost all of their existence lying flat
Their diet is entirely liquid
Their lower oesophageal sphincter (junction between the food pipe and stomach) is immature and lax
All of this conspires to make it easy for stomach contents to reappear at inopportune moments. It also means that this problem is transient and usually resolves around 6 months of age once babies are being weaned onto solid food and can sit up. In a recent study, 50 - 60% of infants experienced physiological reflux until 6 months of age, falling to ~10% by one year.
What is GORD?
GORD stands for Gastro-oesophageal Reflux DISEASE, implying a pathological element. This is more clearly defined in adults, who should not routinely be experiencing reflux and for whom it can be painful and cause further disease.
In infants, this definition is much less clear. To paediatricians GORD would likely apply when a childs growth is faltering due to lack of nutrients, or they have evidence of oesophagitis (inflammation of the oesophagus). These two conditions are rare and are usually managed by specialists.
The most common problem contributed to reflux is crying. All babies cry, and some babies cry a lot. It is not always clear why babies are crying, and often reflux is considered a likely culprit.
(For more on the mysteries of baby crying and other weird things they do see previous post here.)
It is extremely difficult to know why babies cry sometimes, and often it is just normal for some babies to cry a lot. However there are some babies who do seem to find reflux distressing.
What can we do about reflux?
There is actually very little that can be done to effectively manage infant reflux. It is essentially a mechanical issue so the most effective management is mechanical, or since it is self-resolving, nothing at all.
The first thing is to check the babies feed volumes if bottle fed. Normal infant feed volumes are around 150 - 180 ml per kg per day. Frequently we will find the baby is getting well over 200 ml per kg per day, in which case no wonder some of it is revisiting you.
The next thing is reducing the volumes of each feed and increasing the frequency of feeds. Smaller volumes given more often during the day will result in the same amount of milk being given in total, but in volumes easier for the stomach to handle. This is hard work but can be effective.
Advice around positioning (i.e., sitting the baby up after feeding for a while) is always given but parents will usually have tried this already.
The final mechanical options are thickening the feed. This can be done with special thickened formula, or with infant gaviscon. At best, the evidence over the effectiveness of feed thickeners on symptoms of reflux (e.g. crying) can be described as mixed, and they tend to cause another problem; constipation. This can be even more troublesome than reflux itself.
Acid suppression in infants
Historically, infants with reflux have frequently been prescribed medicines to suppress acid production in the stomach, including H2 receptor antagonists such as ranitidine and proton pump inhibitors such as omeprazole. These would be considered first line treatment for GORD in adults. However, as any paediatrician will tell you, children are not just small adults!
Acid suppression for reflux in infants doesn’t make much sense. Infants stomachs are much less acidic than adults, not reaching adult pH levels until they are around 14 years of age.
The issue for most infants is not the acidity of the stomach contents, it is the uncomfortable feeling of milk regurgitating. Suppressing stomach acid does nothing to stop the process of reflux, it simply reduces the acidity of stomach secretions.
Despite this, their use was until recently quite widespread2. So what is the evidence of their efficacy? By this point, it may not surprise you to hear that there is little to no evidence of these medicines making any difference to the symptoms of infant reflux at all, based on a comprehensive Cochrane review (COI: I was a co-author of the original review in 2014).
The harms of infant acid suppression
The microbiome has become a hot topic in recent years. There is intense interest in the normal flora of your bowel, and this includes how it influences the development of a normal immune response during infancy.
Given stomach acid exists for a good reason - to keep the bad bugs out of your bowels - it stands to reason that suppressing this might alter your microbiome, which may have unintended consequences for your health.
There is a growing body of evidence suggesting that the use of acid suppression in infancy is associated with an increased risk of multiple conditions during childhood, including;
Whilst studying potential harms like this is difficult, there are now several streams of evidence with consistent findings and a highly plausible mechanism.
Summary
Infant reflux is ubiquitous and self resolving. For some babies it may cause distress, and this can be extremely difficult for parents to manage. Mechanical solutions may offer some benefit. There are no pharmacological treatments with proven efficacy, and the use of acid suppression is associated with significant potential harms. There may be exceptional instances where it is warranted, but this should be under the supervision of specialist physicians.
As prescription of acid suppression in infants has been recognised as a significant problem, there are some excellent resources aimed at reducing their use:
College of Family Physicians of Canada
No, I will not refer to it by its other name
In some countries their use continues to rise significantly, however use has decreased over the past 10 - 15 years in the UK.
Very interesting. I'm pondering switching to calling acid reflux GORD after reading because I love the British spelling of oesophageal. It would also require using the acronym TOE for trans-oesophageal echocardiography!, thereby moving from a golf reference to anatomic reference.
Interesting article, thank you! I don't usually comment because I'm not a medical practitioner but this article felt very relevant to my experience with my daughters as babies. My first daughter spit up so much she covered our apartment in milk - I never saw a doctor because she was growing and happy. My second daughter screamed and arched after every NG tube feed, no spit up, and getting doctors to listen and treat her was so hard. It turns out she has a rare genetic condition which commonly results in severe acid reflux, among many other medical conditions and disabilities. Your article helps me understand the difficulty with doctors not wanting to treat her. Once her genetic condition was diagnosed she had no issues getting treated and she's been on omeprazole/lansoprazole for 6 years. It's a blessing for her because without it she's in so much pain and for her reflux has not gone away. It likely won't. Having seen this play out from the parent perspective it was interesting to read an explanation of the reasoning behind why doctors may not want to treat reflux in otherwise healthy babies.