Did you know that reflux medicines (aka Proton Pump Inhibitors or PPIs) are among the most overused drugs in the world?
Reflux medicines make the list of top ten most prescribed drugs in the world. If your baby or child is on one, your gastroenterologist (GI doctor) probably prescribed it to lower stomach acid for presumed gastroesophageal reflux disease (GERD).
In your doctor’s eyes, these drugs are considered generally well tolerated and are not considered harmful to adults or even children. The problem is that (some of ) these drugs are only approved for short term use in children – but, it’s common to leave babies, toddlers or older children on them for months or even years at a time. I see this in my pediatric nutrition practice all too often! When these drugs are taken for months at a time, there is potential for serious side effects that can cause lasting digestive and immune system issues.
Another dilemma with getting a PPI for GERD is that the diagnosis is typically based on a brief conversation with mom about spit up, colic, or vomiting. Rarely seen is an actual diagnostic test for whether someone needs this drug – in adults or kids. Measuring stomach acid is the confirming diagnostic for “excess stomach acid”. This requires an invasive endoscopy procedure which must be performed under sedation or anesthesia. Even with endoscopy, if inflammation is seen in the esophagus’ tissue during that procedure, it is assumed that excess stomach acid is the cause. The only way to assure if this is actually true is to add a pH probe to the endoscopy procedure. This probe measures the pH (acid level) in the stomach.
Another way to confirm is to observe stomach acid actually entering the esophagus (that is, stomach contents are going up instead of down) with a barium swallow and observing results, live in real time, on X ray.
If a pH probe shows that the stomach is indeed too acidic, a PPI may indeed help. If the problem is normal acid levels that gurgle backwards up in to esophagus, a PPI may help, or may not help at all – it may make the problem worse over time. And here’s the other twist: Even weak stomach acid (at a pH of 3 or 4) is still too acid for delicate esophagus tissue. But it’s too weak to do a good job of moving food out of the stomach and into the small intestine. So, this leaves food sitting in the stomach, and gurgling back up in to the esophagus. A PPI may temper that burning sensation a bit, but it will not solve the problem of getting food moving along in the other direction – in fact, it will make food sit longer in the stomach, giving more opportunity for the food to gurgle backwards into esophagus. This is exactly how many of my young patients end up needing more, more, and more reflux medicine… until it stops working even at the highest dose.
Here’s When To Intervene
Babies normally have some spit up or vomiting. If your baby is clearly in pain, crying hard, unable to eat, and not growing or gaining, then a PPI can offer some temporary relief. Likewise, if your doctor saw highly irritated esophageal tissue on an endoscopy, then a short term use of PPIs may soothe the situation. Babies should not be left to cope with pain when a medication can immediately help.
Create a strategy up front with your doctor to use those tools temporarily. A switch in feeding can often make a big difference. Changing a breastfeeding mom’s diet can help, by removing foods like dairy, eggs, or high FODMAPs foods like onions, garlic, apples, prunes, or broccoli.
Formula fed babies can improve with a switch to something more digestible: Consider hydrolyzed formulas like Alimentum Ready To Feed, or formulas with a different protein profile like Gerber Soothe (more whey, less casein), or a goat milk formula option. All of these are worthy measures before placing your baby on a reflux medicine.
There are also gentle herbal glycerite tinctures for children that soothe the stomach and gently encourage normal digestive function. One of my favorites is Gaia Herbs Tummy Tonic, which I’ve used with success for many years in my pediatric nutrition practice. This herbal tincture is one of may herbal blends known as digestive bitters. They gently stimulate the stomach to produce its own normal array of acids so digestion can begin.
Since reflux drugs lower stomach acid, they also lower the protection we get from having that natural acidic barrier between the big bad world and our bodies. This acid barrier is supposed to be very acidic. A gastric juice pH as low as 1.0 is normal. This can prevent harmful bacteria that may be in our mouths from entering the body. But if the stomach pH gets too high – that is, if it becomes less acidic – this matters for 3 key reasons:
- Potentially harmful oral bacteria can work its way into lower parts of the GI tract, a trip that would not be made possible when there is enough stomach acid. Once it makes its way into the GI tract, foreign bacteria can cause such infections as Clostridium difficile, Salmonella, Campylobacter as well as Escherichia coli.
- When harmful bacteria invade the GI tract, they can begin to overgrow and compete with the “good bacteria” that we rely on to help us with digestion and immune system support. Over time this impacts the diversity of our microbiome and can cause dysbiosis, a condition where the good bacteria is reduced and too much bad bacteria is allowed to grow – creating an environment that can also lead to yeast overgrowth, constipation, irritable loose stools, picky eating, food intolerances, food allergies, or pain.
- Too much of the wrong kind of bacteria and not enough of the good kind can lead to inflammation in the gut, which then cause the gut wall barrier to be more permissive – that is, the tightly compacted tissue structure inside the gut wall gets a little loose, with microscopic spaces that can allow larger molecules than normal to enter circulation in the body. These can be partly digested food proteins, toxins, or microbial organic acids. This is known as “leaky gut” and people may experience all sorts of discomfort or chronic systemic inflammation as a result.
My child was treated with a PPI. Now what?
Long term PPI use can disrupt healthy gut microbiomes, and favor yeast or fungal species. Over time, these drugs can make weak, picky appetites, weak protein digestion, weak absorption of minerals like iron and zinc, and poor B12 absorption. You can…
- Use my Sensory Nutrition Checklist to look for signs that certain nutrients are not being well absorbed. Supplements can help cover the deficits in the short term, as you repair your child’s appetite.
- Explore with a stool test that assesses helpful bacteria as well as pathogens, fungal species (yeasts), and disruptive commensal species.Stool study findings can be addressed with non prescription tools in many cases, such as rotations of certain probiotics or herbal compounds that discourage fungal or disruptive bacteria species. Most of these tests include measures for inflammation and digestive function too. This is an easy way to sort out what is going on. Be sure to work alongside an experienced integrative and functional practitioner when ordering your child’s stool test to understand and interpret the results and what the best protocol might be to improve your child’s microbiome health. They are likely to have knowledge and experience with therapeutic herbs and probiotics that can be used to help resolve your child’s GI issues in the most gentle way possible. Clearing gut dysbiosis directly in this way can accelerate restoration of normal digestion.
- Join my Nutrition Cafe secure on line group chat, where we tackle topics like this in detail on a regular basis in HIPAA secure live zoom chat with me.
- Change up your baby’s feeding routine per suggestions above. Find easy to digest foods; these are usually low FODMAPs fruits, vegetables, and grains, plus gentle protein sources like white fish, chicken, or turkey. Avoid fermented foods or bulky high fiber foods at first; these may become easier to handle later on.
- Avoid high potency multi strain probiotics at first. Start with a simple one like Klaire Factor 1 or Klaire ABx Support. More complex products like GutPro may be better tolerated later on.
- Gently restore stomach acid with a combination of a digestive bitters tincture like Tummy Tonic, with 1/4 teaspoon Braggs Apple Cider Vinegar, at meals or feedings. This can be mixed with pleasant tasting juice such as a small amount of elderberry juice or pineapple juice (which has some natural enzyme in it too). Other helpful soothers and gentle gastric stimulants are peppermint, ginger root, lemon rinds or lemon juice in water, or chamomile tea. Use these regularly and steadily for a gradual repair of gastric juice.
Give this project some time, especially for kids who have used a PPI for more than 3-4 months. Gradually a healthy appetite without bloating, hiccups, gas, constipation or pain can be restored.
Thanks to Rosanne Walsh, AADP board certified nutrition and health coach and RD intern for building this blog post with Judy!