Treating reflux in babies with PPIs: what are the long-term side effects?

It’s not unusual for babies to spit up after a feed, but if your little one is vomiting frequently, seems to be suffering from discomfort regularly and is losing weight, it could be cause for concern.

While these symptoms could indicate any number of medical conditions, two of the most likely causes are gastro-oesophageal reflux (GOR) or gastro-oesophageal reflux disease (GORD) – which are often treated using a prescription for proton pump inhibitors (PPIs). But what’s the difference between GOR and GORD and are there long-term side effects of treating babies with PPIs?

Reflux in babies: What is Gastro-oesophageal reflux (GOR)?

GOR is the movement of gastric contents into the oesophagus, often with effortless vomiting, or possets (spitting up). Although it’s not unusual for this to occur several times a day in healthy infants, simple GOR can cause distress to parents and generally requires reassurance, support and guidance from a healthcare professional.

GOR is common, affecting at least 40% of infants. It usually begins before 8 weeks of age, peaks at about 4 months and, in the majority of cases, resolves by the time the baby celebrates its first birthday. It’s important to note that GOR does not cause crying and irritability in healthy infants. Infant crying generally peaks at 6-8 weeks anyway, so some babies with simple GOR may also be unsettled.

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Reflux in babies: What is Gastro-oesophageal reflux disease (GORD)?

An infant is considered to have GORD when GOR causes vomiting along with the following symptoms:

• Refusal to feed
• Irritability with feeding
• Aspiration and recurrent pneumonia
• Chronic cough or wheeze
• Failure to thrive
• Haematemesis (vomiting blood)

While GOR occurs in healthy, thriving babies and doesn’t require any specific medical investigation or management, it’s important to remember that GORD is not a common cause of unexplained crying, irritability or distressed behaviour in otherwise healthy infants.

If your baby is exhibiting these symptoms, an alternative diagnosis to consider includes cow’s milk protein allergy (CMPA), which presents with similar symptoms to GORD. If this is the case, you may also notice blood or mucous in the baby’s stool, chronic diarrhoea or atopic risk factors.

What is a PPI & how do they work? 

Reflux in babies is often treated with proton pump inhibitors (PPIs), which are gastric acid suppressants: medicines that reduce the amount of stomach acid made by glands in the lining of your stomach, which is something that babies need in order to digest food. Two of the most commonly-prescribed PPIs are Nexium and Prilosec.

When are PPIs commonly used?

“The use of PPIs in the management of infants with excessive crying based on a presumptive diagnosis of GERD remains common practice among paediatric caregivers despite the lack of any evidence-based treatment efficacy or utility in these patients,” explains specialist paediatrician Dr Eduard Bruckmann.

In fact, guidelines for GOR specifically state that PPIs are not generally indicated in these cases as there’s no evidence to support the use of acid-suppressant therapy. In these cases, the use of acid suppression for unsettled infants is not effective and may actually cause harm.

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When should a PPI be prescribed for a baby?

When GORD or something similar is considered the most likely cause of excessive crying, definitive investigation is needed, and only in selected infants might a short trial of acid suppression therapy be indicated. In these cases, referral to a paediatrician is necessary – and paediatricians may refer the patient on to paediatric surgery if the trialed medical treatments fail.

What are the side effects associated with the use of PPIs in babies?

Studies have indicated that prolonged PPI therapy – using the medication for a year or longer – may lead to an increased risk of:

Community-acquired pneumonia

A study showed that the use of acid-reducing drugs is associated with a 30% increased risk for developing pneumonia.

Gastroenteritis

As PPIs cause a big reduction in gastric acid, long-term use can result in an increased susceptibility to bacterial infections.

Fractures

Patients are at a higher risk of future fractures after prolonged use of PPIs, which is due to decreased absorption of calcium from the intestines.

Micronutrient deficiencies

Another risk is deficiency in certain micronutrients, specifically, PPIs have been associated with an increased risk of vitamin and mineral deficiencies . The micronutrients that are most commonly impacted include vitamin B12, iron, calcium and vitamin C.

What’s the alternative to treating babies with PPIs? 

Luckily, when it comes to treating reflux in babies, even small changes can make a big difference to the child’s comfort levels.

Positioning

While inclining the sleep surface is not recommended in infants due to the risk of SIDS, holding the infant in a head elevated position for 20–30 minutes after feeding may reduce the symptoms of GOR.

Thickened feeds

In bottle-fed babies, thickened feeds may help to reduce the frequency of vomiting because the thickener binds to the stomach acid and reduces the spit up. There are commercially available anti-reflux infant formulas that contain thickener (such as Novalac AR, NAN AR or Novalac AR Digest) or, alternatively, a thickening agent can be added to expressed breast milk.

Don’t, however, give a child thickened formula at the same time as a PPI because the PPI suppresses the stomach acid and the thickener needs the acid to bind to in order to work – so the two products essentially cancel each other out and neither treatment would be effective.

Optimise feeds

Observation and assessment of feeds by an experienced lactation consultant or Maternal Child Health Nurse (MCHN) can be helpful. Assess feed volumes in formula-fed infants to identify if you might be overfeeding. Reducing the volume of each feed can help reduce regurgitation but should only be considered if the portion is considered excessive for an infant’s weight. Consider a trial of smaller, more frequent feeds in these infants if it’s practical to do so.

Conclusion

So, while PPIs can be effective in treating certain conditions, prolonged use may have a lasting impact on a baby’s health and there are a number of interventions that could be considered prior to prescribing PPIs. It is clear that paediatricians believe it is always better to try the nutritional route to ease reflux before using harsh medications which may affect your baby.