The Reflex To Treat Reflux
Why do we overmedicate babies for heartburn?
In many patients, heartburn has little to do with acid reflux. Most likely the symptoms come and go randomly, with no relation to reflux or any medication use. Further, while acid blockers are useless against nonspecific belly pain—because there's no hydrochloric acid in your intestines, liver, or other organs of the digestive tract—doctors frequently prescribe them for so-called "non-ulcer dyspepsia." The British Medical Journal in 2008 estimated that anywhere from one-quarter to three-quarters of all acid blockers like Nexium were prescribed for no good reason.
Because almost 20 percent of all adults complain of reflux-type symptoms, doctors tend to throw the drugs around at the first mention of mild heartburn. Ideally, physicians should endorse simple dietary changes (avoiding caffeine, high-fat meals, and eating just before bedtime), mention cheaper alternatives (like Tums), and explain the random ups and downs of the pain. But they don't. Across the globe, Nexium is over-prescribed for the most banal of reasons: It's less work to write a prescription and pretend the problem is solved.
The consequences of this worldwide clinical laziness are serious. Once you start the drugs, it's very, very hard to stop; even the stomachs of healthy people become "addicted" to the drugs. In 2009, studies showed that volunteers with no heartburn symptoms who took the anti-reflux drugs for two months actually experienced heartburn and reflux when they tried to stop. Further, the acid blockers increase the risk of fractures by one-quarter in women, are associated with more deaths after angioplasty, and increase the risk of major gut infections.
And now the war on stomach acid has a new front: babies with colic. Normal infants reflux all the time (the average preemie, for example, has 71 minor spit-ups daily), but fewer than one in 300 has any evidence of damage to the esophagus. Randomized studies regularly show that acid blockers do nothing to help baby reflux. Worse, drugs like Nexium or Zantac (which blocks acid in a slightly different manner) may increase brain bleeds and gut damage in preterm infants as well as the risk of food allergies in older infants.
Yet, in parallel with the jump in adults, the number of acid-blocker prescriptions for colicky infants recently quadrupled. Bemoaning this trend, Philip Putnam of Cincinnati Children's wryly observed that "gastric acid rivals mucus as the most maligned secretion from the body."
The overuse of drugs like Nexium isn't a new problem. For years, doctors prescribed COX-2 inhibitors like Vioxx and Celebrex, though they worked no better than Tylenol and ibuprofen. Pediatricians use antibiotics to treat almost half of all kids with colds, though the powerful drugs do no good and drive up the number of resistant microbes. Can we really blame the drug companies for these messes? Malcolm Gladwell, writing on the prescription drug crisis, notes, "For sellers to behave responsibly, buyers must first behave intelligently." For many adults with heartburn and for many babies with colic, doctors regularly write useless prescriptions and insurers happily pay to fill them.
That's the little-known secret of drug expenses. Our nation's drug bill has are risen not because the drugs cost more: Only one-third of the 9 percent annual jump comes from higher prices. The truth is that grown-ups and now babies are simply taking more pills. This situation will persist until health insurers, who inexplicably cough up billions of dollars for me-too drugs like Nexium, demand value for their outlays.
In the meantime, the next time your pediatrician suggests Nexium, Prilosec, or Zantac for your baby's mild spit-ups, ask her to explain their necessity better. Tell her you don't need any fancy pills. You would prefer a far more powerful therapy—words of explanation.
Darshak Sanghavi is Slate's health care columnist. He is chief of pediatric cardiology and associate professor of pediatrics at the University of Massachusetts Medical School as well as the author of A Map of the Child: A Pediatrician's Tour of the Body. Follow him on Twitter.
Photograph of man in distress by BananaStock/Thinkstock.