I believe that Nexiam (and other proton pump inhibitors) are being overprescribed in private practice. It might have become a fashion drug, being conveniently packaged in the small doses used in young infants. Recent medical literature does not support this phenomenon of widespread non-restrictive prescribing of proton pump inhibitors for infants with gastroesophageal reflux. This is mirrored in the current recommendations from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). In fact, we might be doing more harm than good.
Why the fuss? Decreasing the stomach acid might have consequences : 1. Increased risk of infection : intestinal infections (especially), upper respiratory tract infections, pneumonia and urinary tract infection. 2. Gastric and small intestinal bacterial overgrowth with a disturbance in the establishment of a healthy microbiota. The role of a healthy microbiota in health and disease, digestion, immunity and allergy prevention is an active field of scientific study at present. 3. Iron, vitamin B12 and magnesium malabsorption with associated deficiencies of these. 4. Negative impact on bone health with a risk of later childhood fractures. Listed other noteworthy potential side-effects of proton pump inhiitors like Nexiam include hepatitis (inflammation of the liver), interstitial nephritis and chronic kidney disease (inflammation of the kidney) and pancreatitis.
"Use of proton pump inhibitors (PPI) is discouraged in infants, except for those with endoscopically documented moderate to severe esophagitis, because of limited efficacy and increased risk for some infectious, metabolic, and nutritional disorders. In a new retrospective database study of over 850,000 children, proton pump inhibitor use prior to one year of age was associated with subsequent fractures during childhood; increased risk was seen with both earlier and prolonged duration of PPI therapy. These findings are consistent with studies in adults showing a link between PPI use and osteoporotic fractures and provide an additional rationale for avoiding or minimizing PPI therapy in infants whenever possible." Uptodate.com, updated August 2019
Why is it prescribed so easily? There is a persistent belief that crying in a young baby might be related to the discomfort caused by acid reflux. Doctors probably feel obliged to try something that might potentially make the crying baby more comfortable. It is difficult to prove or disprove that a baby is or is not troubled by his or her reflux. Young babies are even prescribed Nexiam for "silent reflux" (where you don't see any spitting up, passive flow or vomiting of milk in-between feeds). This situation opens up the door for unnecessary and prolonged proton pump inhibitor medication. Even a diagnostic trial of proton pump inhibitor therapy for a few weeks (to diagnose symptomatic reflux) is not supported by the current ESPGHAN guideline.
"Several randomised trials and a systematic review concluded that proton pump inhibitors are not valuable in infants with irritability or regurgitation, because they do not improve symptoms as compared with placebo". Uptodate.com, updated August 2019
"..., The more difficult subgroup of patients is the group of infants presenting with fussiness, crying and arching with or without spitting but who otherwise are thriving. In this population. there is often intense pressure by families to start anti-reflux therapies or pursue diagnostic testing because of the perceived severity of symptoms. In the absence of warning signs, diagnostic testing and/or therapies including acid suppression are not needed if there is no impact of the symptoms on feeding, growth or acquisition of developmental milestones." ESPGHAN guideline, 2018
Most babies will have reflux in the first few months of life at least. Many settle by four months; up to 12 months is still considered normal. With regular feeding neutralizing stomach acid, non-acid reflux episodes are common (especially shortly after feeding) and not bothersome to a baby.
Is Infant Gaviscon an alternative? No. It is intended for short term (days) use only. The chronic use of antacids like Gaviscon is not recommended due to adverse effects again on bone health (hypophosphatemic rickets) and aluminium toxicity in children with kidney disease. What about other medications? Motilium (prokinetic) : not recommended. Erythromycin (prokinetic antibiotic) : not recommended. Zantac (histamine antagonist) : could be beneficial with endoscopically(camera)-confirmed ulcerative esophagitis and gastritis, but is not available. Ulsanic : no clear benefit as yet. We should not be prescribing these medications easily.
What are the recommended conservative measures one should rather try? 1. Don't be overly concerned. Gastroesophageal reflux is normal and resolves in 98% of infants with gastroesophageal reflux before 12 months of age. Warning signs of pathological or an abnormal level of reflux are : failure to gain weight, blood-stained vomit, regular chest infections and episodes of choking/struggling to breathe related to an episode of reflux. 2. Feed smaller volumes more regularly. 3. Thicken baby's expressed breastmilk or formula with rice cereal or oat cereal or, if only on formula, try an anti-reflux (AR) formula, like NAN AR 1 or Novalac AR 1. 4. It could be a manifestation of protein allergy. For breastfed babies, mom could attempt a 2-4 week trial of dairy exclusion. For formula-fed babies, an extensively hydrolysed formula like Pepticate could be tried. 5. If someone smokes at home, stop smoking. Passive smoke inhalation promotes reflux in your baby.
Babies are drinking too much milk in the 6 to 18 month window period. This period is critical in establishing healthy eating behaviour. Too much milk not only deprives the body of nutrients it needs from solid foodstuffs, it also leads to iron deficiency and contributes to chronic or recurrent constipation. Riekie Van der Vyfer, a local dietician based at Quenet's Family Pharmacy, gives some tips to help getting baby off the bottle (and breast).
Lonette De Vries, a registered occupational therapist in Robertson, has been kind enough to suggest a few developmental exercises you can do with your baby in the first few months of life. Have fun!
Yes, it is available in Worcester. A few drops of your baby's blood can be collected onto a blood card in the first few days of life (best on the day of discharge) to screen for a number of metabolic and other inherited diseases (see below for the complete list). As a screening test, the aim is to identify newborns that require further, definitive testing. The benefits include early diagnosis and potential treatment of these relatively rare (1 in 4000 babies affected), but potentially serious and lifelong, conditions. They can be quite difficult to diagnose (if one waits for symptoms and signs to appear) and by the time they are, some of the complications may be irreversible. It is strongly recommended to have the screening test done if there is a family background of one of these conditions. Why isn't everyone having the test for their baby? It is relatively expensive (currently up to allmost R1600) and your medical aid probably won't cover the cost.
Conditions screened for with the newborn screening test :
Amino acid disorders : Citrullinemia type 1, classic phenylketonuria, homocystinuria, maple syrup urine disease, tyrosinemia type 1.
Organic acid disorders : 3-hydroxy-3-methylglutaric aciduria, 3-methylcrotonyl-CoA carboxylase deficiency, glutaric acidemia type 1, holocarboxylase synthase deficiency, isovaleric acidemia, methylmalonic acidemia (cobalamin disorders), methylmalonic acidemia (methylmalonyl-CoA mutase), propionic acidemia, beta-ketothiolase deficiency.
Disorders of fatty acid oxidation : carnitine uptake defect/ carnitine transport defect, medium-chain acyl-CoA dehydrogenase deficiency, very long-chain acyl-CoA dehydrogenase deficiency.
Disorders of carbohydrate metabolism : classic galactosemia.
Endocrine disorders : congenital adrenal hyperplasia, primary congenital hypothyroidism.
Other disorders : biotinidase deficiency, cystic fibrosis.
More information :
Newborn screening in South Africa
Newborn screening in the USA
Colic is a descriptive, subjective diagnosis : it only means that your young baby is crying excessively in the first few months of life. The crying could be associated with clenching of the fists, pulling up the legs and passage of a wind. It is a diagnosis of exclusion : colic can only be diagnosed by your doctor once other causes of crying in a young baby have been excluded. No quick answer over the phone, unfortunately. Your baby is not the only one, however : 25% of normal babies have colic.
Although there are theories surrounding the cause of colic, we actually don’t understand why it happens. Theories include :
- Temporary cow's milk protein allergy (some babies respond to maternal dairy exclusion if breastfed or to switching to an extensively hydrolysed formula like Pepticate if formula-fed)
- Temporary intolerance to a maternal diet containing cauliflower, cabbage, broccoli, bok choy, brussels sprouts, onion or chocolate (if breastfed)
- Excessive gas in the bowel (fermentation due to bacterial overgrowth in the colon/ inability to effectively pass winds)
- Temporary lactose intolerance (some colic medications contain lactase, which breaks down lactose)
- Dysbiosis (the theory that different types of bacteria populating the young gut may lead to inflammation, poor digestion, excessive gas production or neuro-behavioral problems). The probiotic strain Lactobacillus Reuteri DSM 17938 has shown promise in the prevention of colic.
- Incorrect feeding technique (underfeeding, overfeeding or infrequent burping)
- Psychosocial and neurodevelopmental theories : Missing the warmth, sounds and body orientation inside the womb environment/struggling to adapt to the external environment, parental anxiety and depression (in part due to parental disillusionment on how a baby should behave), prevalence of a parental rearing belief that they may "spoil" the baby if not allowed to self-soothe. Some babies just want to be wrapped close (even skin-to-skin) to mom. White (background) noise can help soothe a baby.
There is no solid medical treatment available that consistently alleviates crying in all babies with colic. My experience has taught me :
- Looking for the perfect colic mixture is probably a wild-goose chase. The evidence for their efficacy and real-world experience in their abililty to decrease crying time is not convincing. If you do however choose a colic drop/mixture, try one which contains fennel, chamomile or lemon balm (try Spasmopep Junior or Colic Calm) - there are at least some evidence for these ingredients.
- Don't discount the role of alternative approaches like chiropractic therapy (or even acupuncture!)
- Antispasmodics (like Buscopan/Scopex/Hyospasmol) allmost never makes a difference
- Antacids (like Infant Gaviscon or Nexiam) is overprescribed and current literature does not support their widespread use in the crying baby
The cloud has a silver lining though : One can rest assured that it is a temporary phenomenon – babies with colic stop crying between 3 and 4 months of age.
1. Tu Mai MD, et al. Infantile colic : New insights into an old problem. Gastroenterology Clinics of North America 2018; 47:829-844.
Breastmilk can be frozen (in a sterilized bottle). If special containers for this purpose aren’t available, you may express into a normal (sterilized) bottle, covering it with plastic or foil to prevent contamination.
How to thaw : swirl bottle with frozen expressed breast milk under running, warm water. Don’t thaw at room temperature : it takes too long, spoiling may occur. Never heat in a microwave. Never refreeze once thawed.
How long can expressed breast milk be stored?
- Fridge ice compartment : 2 weeks
- Freezer : 3 months.
Wash hands and all feeding utensils well.
Boil all feeding items for 5 minutes. Close cleaned, dry bottles until used.
Boil fresh water for 5 minutes; allow to cool down to lukewarm before pouring into bottle.
Prepare one feed at a time. Only use the scoop provided with the formula - scoop sizes vary between brands. Read the label carefully to see the recommended volume of the feed according to your baby's age and/or weight and the amount of water to be mixed with a scoop of formula powder. Level each scoop with the back of a clean, dry knife.
If formula needs to be warmed, it should be done with a bottle warmer or by placing the bottle in a container of warm water. Do not warm in a microwave (creation of hotspots with the risk of causing burns). Do not warm for longer than 15 minutes (certain bacteria may start to proliferate). An appropriate temperature for the formula is between room and body temperature. Test a few drops on the inside of your wrist to check the temperature before you offer it to your baby.
Any infant formula not consumed within 2 hours should be discarded. Leftovers should never be reheated, refrigerated or saved for the next feed.
If your baby is jaundiced, be sure to know when your paediatrician would like you to have the jaundice test to be repeated. In general, if the jaundice test was done on the day of discharge from hospital, it is recommended to have it repeated within the next 48 hours. It is also recommended to repeat testing if your baby is still jaundiced after 2 weeks.
Feeding And General Baby Care
If you experience any feeding difficulties or if you have any questions regarding routine care of your baby, please contact Sr Anelle Greyling on 083 564 6722 for feeding advice and support.
Regular Weighing Of Your Baby
It is recommended that you have your baby weighed regularly in the first few weeks – weekly initially for the first 2–4 weeks and then biweekly thereafter.
If Dr Stander attended to your baby after his or her birth in hospital, you will be contacted to arrange a follow-up visit at the practice within 5 days of discharge from hospital, as well as an appointment for a routine check-up at 6 weeks, usually arranged for the same day you have a check-up with your obstetrician.
Routine immunizations are done at 6 weeks, 10 weeks and 14 weeks in the first few months of your baby’s life. This is irrespective of whether your baby was born prematurely or at term. The practice will arrange for your baby’s immunizations at our in-house immunization clinic, Kleinding Kliniek.
It is recommended to have your baby’s hearing tested after birth. The hearing test can be arranged with the following audiologists in Worcester :
Elda Van Dijk 082 331 8889 (66 Fairbairn Street)
Ula Rabie 023 347 4176 (30 Russell Street)
Helmien Van Rooyen 072 179 8486
If you have any further questions or experience any problem not addressed above, be sure to give the practice a call – we will gladly assist you.
Office hours 08h00-16h30 023 342 2333
After hours 079 294 3199
Consult a doctor: