August 26, 2019


Since the dawn of time, mothers have noted that an infant will spit up their breastmilk not too infrequently during the first six months of life. This is a norm. Somewhere in the last 30 years, we started medicalizing this reality and inappropriately calling it GERD or gastroesophageal reflux disease when the vast majority of these events are benign spit up.

A new class of drugs to treat reflux called proton pump inhibitors,

PPI, came online a few decades ago. They are strong stomach acid suppressing drugs initially developed to treat serious diseases like Zollinger Ellison Syndrome where gastric acid is overproduced.

In the 2019 July edition of the Journal Pediatrics, Dr. Malchodi and colleagues looked at fracture risk in children that were treated with these medicines during infancy (<1year old). They studied 851,000 children and found that 11% were treated with an acid suppressing medicine. (This is way higher than our clinic's percentage) Of those 11% treated, only 12% received the PPI class of acid suppression therapy alone while the remainder of the children were treated with either an H2 receptor blocker (much weaker acid suppression) or in combination with a PPI.

They found that by less than 5 years of age on balance, a child would suffer a bone fracture 21% more frequently if they were treated with a PPI and 30% more frequently if they had double acid suppression therapy with a PPI and H2RA drugs. They also noted a trend to increasing fracture risk with the total number of days treated or earlier initiation of the medicine therapy. (Malchodi et. al. 2019)

This article adds to reams of data that these drugs are not good for us at any age but especially not in infancy. We now have data (mostly adult) that these drugs can cause an increase in the following:

Chronic kidney disease
Dementia (weak association)
Small intestinal bacterial overgrowth
Micro and macro nutrient deficiency
Allergies to food and environmental proteins
Blood and lung infections
Necrotizing enterocolitis
Gastic type cancers
(Slaughter et. al. 2018)(Vaezi et. al. 2017)(Kinoshita et. al. 2018)

There are those in medicine who disbelieve that these medicine induced risks are legitimate. I ask the simple question as always: does it make any physiological sense to reduce the stomach acid that is naturally at a pH of 1-2. When we reduce the acid load medically we induce a higher pH which is less functional for digestion, pathogen killing and many other human needs. By reducing a natural function in the body, we must incur a cost. That is how nature works. Therefore, I strongly believe that these medicines are not beneficial unless absolutely necessary after all other routes of healing are tried.

How do we prevent and/or recognize normal spit up versus the pathological variety?

When it comes to the non-pathologic causes of spitting up, the answer is rooted for the vast majority of children in poor coordination of muscle closure at the esophageal/stomach junction. This allows the milk to reflux back up the esophagus when the stomach contracts. This is not a big problem and it fades with time without treatment.

For those children with pathologic reflux where they are actually refluxing acid, have pain sensations and cry alot, then we need to look deeper for a root cause. In our clinic, we find that milk protein intolerance accounts for a large percentage of these children. Removing dairy from a mother's diet or switching to a hydrolyzed formula like Alimentum can and usually will stop the problem of painful reflux. A smaller percentage of patients require avoidance of soy and corn proteins as well. Maternal or infant elimination diets have had great positive effects on this disease entity in our clinic.

For example, we have children that are formula fed and fail regular formula, soy based and even hydrolyzed milk of the powdered type because the powdered variety uses corn syrup as the sugar base where the liquid variety only uses sucrose, plain sugar. Ultimately, most of these children do very well on ready to feed hydrolyzed formulas.

What this says about our cow's milk based formulas is problematic and not in the scope of this article but makes me worry about the animal care techniques of modern farming.

Mechanical issues: Because of the lack of muscular coordination in a refluxing child, positioning a child upright for the hour after feeding can help the child use the advantageous force of gravity to keep food down. This positional change may make a significant difference in refluxed material.

For more severe refractory cases of reflux that do not respond to positioning or a formula/elimination diet, it may be necessary to use an antacid medicine. H2RA medicines like Zantac are first line therapies with limited to significantly reduced side effect risk. If they fail, then switching to a PPI makes sense.

The key for the rare child that requires medicine is to follow a few important protocols. First, use the lowest dose to control and resolve the issues. Second, use the shortest duration of drug exposure to control and resolve the issues. These refractory to care children likely require a referral to a gastroenterologist for further evaluation.

Know your physiology and risks,

Dr. M

Kinoshita J Neurogastro Article
Malchodi Pediatrics Article
Slaughter J Pediatrics Article
Vaezi Gastroenterology Article