Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1070-1071 (doi:10.1542/peds.2008-0356)

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LETTER TO THE EDITOR

Overprescription of Antireflux Medications for Infants With Regurgitation: In Reply

Vikram Khoshoo, MD, PhD
Dean Edell, MD, MPH
Pediatric Specialty Center,
West Jefferson Medical Center,
Marrero, LA 70072

The letter by Savino and Castagno confirms our data¹ and suggests that trends for overprescription of antireflux medications exist widely. Similar trends have also been reported for adults.² We would like to clarify some issues by using additional data.

TREATMENT PRACTICES

Responses from 3 large pediatric gastroenterology practices from different regions suggested that an average of 76% of the infants referred to them were already taking acid-suppressing agents, which implies that generous use of these medications is widespread. Barron et al have reported a >700% increase in prescriptions for proton-pump inhibitors (PPIs) for infants between 1999 and 2004.³ Less than 10% of these infants had any diagnostic testing performed. Physicians may simply be using antireflux medications as a "therapeutic trial" and getting an erroneous impression that a favorable response in some patients is a result of the medication rather than "time effect" and unjustly strengthening their belief about the efficacy of these medications.

DIAGNOSTIC TESTING

We found that 64% of pediatricians use upper gastrointestinal barium studies, a study with poor sensitivity and specificity, to diagnose reflux.

CONSERVATIVE TREATMENT

We found that (1) positioning is correctly advised by 91% of pediatricians; (2) 7% address avoidance of cigarette smoke; (3) 38% believe that PPIs reduce regurgitation; (4) thickened feeds are advised for 81% of patients; (5) appropriate advice for thickening is given to 15% of patients¹; and (6) the recommended thickening with 1 tablespoonful of dry rice cereal per ounce of formula⁴ is problematic in real life. Thirty mothers of infants with regurgitation were asked to measure 4 tablespoonfuls and 4 heaping tablespoonfuls of rice cereal by using a tablespoon. The weights for 1 tablespoonful were 1.1 to 3.5 g (mean ± SD: 2.57 ± 0.67 g) and that for 1 heaping tablespoonful were 3.5 to 4.6 g (mean ± SD: 3.93 ± 0.28 g). Because of this wide margin of error, we feel strongly that the recommendation should be to use 1 heaping tablespoonful of cereal per ounce rather than 1 tablespoonful, which will more consistently measure 4 g of cereal and improve accuracy in feed composition. The nutritional composition of such a formulation is acceptable.⁵ Isocaloric (3528 J [840 kcal]) smaller-volume thickened feeds are comparable to unthickened feeds for protein content (18 vs 18.9 g), lower in fat content (30.7 vs 46.4 g), and higher in carbohydrate content (128.6 vs 90.7 g).⁵

ADVERTISING

Wide gaps in knowledge cause intellectual vulnerability that could be easily exploited. A recent advertisement for a PPI implies that coughing, abdominal discomfort, fussiness, food refusal, and a bad taste in the mouth are invariably caused by reflux and the use of their PPI is indirectly urged, without disclaimers, to fix these symptoms. The causal relationship of these symptoms with reflux has not been proven beyond doubt. There are few objective data to suggest that treatment of children for these symptoms with a PPI will lead to definitive improvement. On the contrary, even irritability, a commonly associated symptom of reflux, does not improve significantly after treatment with a PPI versus a placebo.⁶ Besides reflux, other conditions commonly associated with chronic cough are asthma, allergies, and postnasal-drip syndrome.⁷ Thus, use of a PPI cannot be recommended routinely for these symptoms without proper investigation.

Unfortunately, these trends are likely to continue as long as there are lacunae in objective data for diagnosing and treating reflux. Meanwhile, concerns about higher risk of community-acquired pneumonia, Clostridium difficile infection, gastroenteritis, and bone fractures with the use of PPIs will loom.^8–10

REFERENCES

1. Khoshoo V, Edell D, Thompson A, Rubin M. Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120 (5):946 –949[Abstract/Free Full Text]
2. Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ. 2008;336 (7634):2 –3[Free Full Text]
3. Barron JJ, Tan H, Spalding J, Bakst AW, Singer J. Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr. 2007;45 (4):421 –427[Web of Science][Medline]
4. Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J Pediatr. 1987;110 (2):181 –186[CrossRef][Web of Science][Medline]
5. Khoshoo V, Ross G, Brown S, Edell D. Smaller volume thickened feeds in the management of gastroesophageal reflux in thriving infants. J Pediatr Gastroenterol Nutr. 2000;31 (5):554 –556[Web of Science][Medline]
6. Moore DJ, Tao BS, Lines DR, Hirte C, Heddle ML, Davidson GP. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr. 2003;143 (2):219 –223[CrossRef][Web of Science][Medline]
7. Edell D, Khoshoo V, Haydel R, Saturno E. Chronic cough in children: etiology using a multispecialty approach. Chest. 2007;132 :605S
8. Canani RB, Cirillo P, Roggero P, et al. Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Pediatrics. 2006;117 (5). Available at: www.pediatrics.org/cgi/content/full/117/5/e817
9. Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005;294 (23):2989 –2995[Abstract/Free Full Text]
10. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006;296 (24):2947 –2953[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Khoshoo, V. Articles by Edell, D. Search for Related Content PubMed Articles by Khoshoo, V. Articles by Edell, D. Related Collections Gastrointestinal Tract Related AAP Red Book topics: Clostridium difficile Social Bookmarking                         What's this?