A lot of babies spit up, and a lot of babies cry. Many parents – and pediatricians – attribute these symptoms to gastroesophageal reflux. Even though there are long-term complications of using reflux medicines (such as increased risk for infections and fractures) – particularly histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) – and the AAP has recommended against the use of these medicines unless there is a definitive GERD diagnosis (which should not be made unless there is poor weight gain, pain, or mucosal injury on endoscopic examination), these medications are still prescribed fairly frequently.
This week, Pediatrics is early releasing a Research Brief entitled, “Overuse of Reflux Medications in Infants” by Dr. Elizabeth Wolf and colleagues at Virginia Commonwealth University and Stanford University (10.1542/peds.2022-058330). The authors used Virginia insurance claims data to identify characteristics of infants for whom H2RAs and PPIs are prescribed.
Seven percent of 270,000 infants were prescribed a PPI or H2RA. Fewer than 1/3 of these infants actually had a diagnosis of GERD. Infants were more likely to be prescribed these medications if they had commercial insurance or had a rural address.
The authors note that, when diagnosing GERD, weight loss and mucosal damage are objective criteria. However, infant pain is difficult to assess, and crying is often interpreted as a sign that the infant is experiencing pain. Regardless of whether there is pain, infant crying is also distressing for parents.
We need to do better with our counseling and reassurance about normal infant crying patterns. Although that takes more time and energy than writing a prescription, the potential downstream consequences of use of reflux medicines should make us be more thoughtful about prescribing them.