Ruminating on GERD

Brian T. Maurer

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I was chagrined to learn recently that 5% of infants are prescribed medication for GERD—gastroesophageal reflux disease, the latest diagnosis du jour in primary care pediatrics.  (Audio-Digest Pediatrics, Vol. 55, Issue 17; September 7, 2009)

Thirty years of practice have provided me a longitudinal perspective for trends in treatment.  When I first got my feet wet in primary care pediatrics, a common complaint voiced by parents of newborn infants was that their babies spit up.  A wise old mentor dropped a clinical pearl in my lap:  “If the baby is gaining good weight, counsel the parent not to worry about it.”

Most of the time this advice worked well, especially if you could demonstrate the infant’s robust weight gain by points plotted on the growth chart.  Some parents remained unconvinced, of course.  For those, my wise old mentor had another pearl of advice:  “If the child continues to spit up, tell the parent to thicken the formula with rice cereal.”  Sometimes that worked as well.

The thing that worked best was tincture of time.  Most babies outgrow their spittyness by their first birthday.  The addition of beikost (solids) by six months of age also helps to curb regurgitation considerably.

Something happened to change this approach to treatment of infant spittyness over the past decade:  H2 blockers and PPIs were introduced into the pharmacological armamentarium of pediatric primary care.

Such drugs were formulated to replace antacids in treatment of acid reflux and gastritis in the adult population.  Once approved by the FDA, these medications were widely marketed by the pharmaceutical companies that manufactured them, despite the lack of evidence that such agents improve physiologic regurgitation.  Double-blind placebo-controlled trials in neurologically intact infants with GER demonstrated no differences in vomiting, crying, fussing and irritability between groups of patients.  Moreover, according to Dr. Colin Rudolph, professor of pediatrics, Medical College of Wisconsin, the risks of drug therapy with PPIs might outweigh the scant benefits in this patient population.

Recently, I evaluated an infant that exhibited heightened irritability after the addition and subsequent increase in dosage of a PPI.  After speaking with the mother at length, I suggested that she stop the medication and follow up with me by phone in two days.  She called back to report that after discontinuing the medication the infant’s irritability dropped off considerably.

Market driven medicine:  when potential profits drive medical practice through aggressive pharmaceutical marketing practices.  But we should always remember that what’s good for the corporation might not be necessarily good for the patient.

About the Author

  • Photo of authorBrian T. Maurer has practiced pediatric medicine as a Physician Assistant for the past three decades.  As a clinician, he has always gravitated toward the humane aspect in patient care—what he calls the soul of medicine.  Over the past decade, Mr. Maurer has explored the illness narrative as a tool to enhance the education of medical students and cultivate an appreciation for the delivery of humane medical care.  His first book, Patients Are a Virtue, recently reviewed in The Yale Journal for Humanities in Medicine, is a collection of patient vignettes illustrating what Sir William Osler called “the poetry of the commonplace” in clinical medical practice. Interested readers can read more of the author's writings at his website and blog.

  • Published: February 28, 2010