Too Much Acid Suppression
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The overuse of stimulant medications in children1 is a topic that I’ve discussed with colleagues and friends on many occasions. Despite the well-founded concerns about these medications, they continue to be prescribed to huge numbers of pediatric patients and more and more adults. A topic about which I haven't had too much discussion is the overuse of acid suppression in infants. I think the use of stimulants in older children with behavior issues, such as attention-deficit/hyperactivity disorder [ADHD], can be compared to the use of acid suppression in infants with behavior issues (ie, colic, irritability).
It seems like some days in clinic, I see an overabundance of irritable, spitting babies who are being given or have been given ranitidine, lansoprazole, or the like, at one time or another. When my son was just a few weeks old, he was one of those colicky, spitting babies for whom an acid suppressor was prescribed. I thought it helped him. Some of my colleagues with children and the parents of my patients have also thought these gastroesphageal reflux disease (GERD) medications brought some relief.
Despite these anecdotal reports about the effectiveness of the GERD medications, a 2011 systematic review concluded that proton pump inhibitors (PPIs) are not effective in eliminating reflux symptoms.2 The review looked at 5 placebo-controlled studies to determine the efficacy of the PPIs. Certainly, more studies are needed, but this systematic review will probably have minimal impact on the use of PPIs in infants at this point, especially because PPIs are generally considered safe. Although their use in children has been reported to be associated with the development of community-acquired pneumonia and acute gastroenteritis.2,3
As with the evaluation and treatment of behavior problems in children, the evaluation and treatment of the irritable, spitting infant must occur in a step-wise manner with the clinician first obtaining a thorough history and performing a complete physical examination. Making a thoughtful diagnosis will guide the therapy. The best a clinician can do in these instances is to choose a therapy for each patient individually on the basis of all available information and the ultimate diagnosis.
Whether it’s ADHD, colic, or GERD, close follow-up and observation for adverse effects or improvement to determine subsequent treatment are essential for optimal patient care. The references below may make you think just a little more before you write your next prescription.