Saturday, April 24, 2010

PPIs (Prevacid, Prilosec) in Pediatrics

As a pharmacist at a compounding pharmacy, I see proton pump inhibitors (PPIs), most commonly Prevacid and Prilosec, prescribed to pediatric patients as young as 7 days old. Based on current evidence, I urge parents to be vigilant not to give these drugs to their babies! I have listed several reasons, including long term side effects below.

1. Current guidelines state that safety and efficacy (how well a medication works) have not been established in infants.

2. The following serious side effects in children after long term use 2 to 11 years have been reported:
-Increasing evidence suggests that acid suppression is associated with increased rates of pneumonia and gastrenteritis in children, and candidemia and necrotizing enterocolitis in preterm infants.
-PPI's have been shown to alter the gastric and intestinal flora.
-Animal studies suggest that acid suppression may predispose to the development of food allergies.
-Decrease in absorption of iron and B12
-Other side effects of PPIs include headache, diahhrea, constipation, nausea, hyperplasia and acute renal failure.

-Lansoprazole: No more effective than placebo in patients 1 month to less than 1 year of age with symptomatic GERD in a multi-center, double-blind, placebo controlled study (Micromedex)
-Omeprazole: Used for the treatment of erosive esophagitis and GERD, or the maintenance of healing of erosive esophagitis has not been found safe or effective in pediatric patients less than 1 year of age. The safety and efficacy for other pediatric uses have not been established (Prod Info PRILOSEC(R) oral delayed-release capsules, suspension, 2008)

4. A study on PPIs in Pediatrics:
-Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Canani RB, Cirillo P, Roggero P, Romano C, Malamisura B, Terrin G, Passariello A, Manguso F, Morelli L, Guarino A; Working Group on Intestinal Infections of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition
-OBJECTIVE: A prolonged gastric acid (GA) inhibitor-induced hypochlorhydria has been suggested as a risk factor for severe gastrointestinal infections. Recently, an increased risk of community-acquired pneumonia associated with GA inhibitor treatment has been reported in a large cohort of adult patients. These findings are particularly relevant to pediatricians today because so many children receive some sort of GA-blocking agent to treat GERD.
It is a multicenter, prospective study. The study was performed by expert pediatric gastroenterologists from 4 pediatric gastroenterology centers
-Inclusion criteria: Children (aged 4-36 months) consecutively referred for common GERD-related symptoms (for example, regurgitation and vomiting, feeding problems, effortless vomiting, choking)
-RESULTS: Total 186 subjects: 95 healthy controls and 91 GA-inhibitor users (47 on ranitidine and 44 on omeprazole). The 2 groups were comparable for age, gender, weight, length, and incidence of acute gastroenteritis and pneumonia in the 4 months before enrollment. Rate of subjects presenting with acute gastroenteritis and community-acquired pneumonia was significantly increased in patients treated with GA inhibitors compared with healthy controls during the 4-month follow-up period. No differences were observed between H2 blocker and PPI users in acute gastroenteritis and pneumonia incidence in the previous 4 months and during the follow-up period. On the contrary, in healthy controls, the incidence of acute gastroenteritis and pneumonia remained stable.

5. Current adult guidelines suggest these medications be used on a short term basis only. If you do decide to put your child on a PPI, please consider doing it short term only (less than 28 days).

If your child is being put on a PPI because he is not putting on weight/having violent spit ups, etc., consider that PPIs may cause malabsorbtion of nutrients by creating an alkaline environment in the stomach and small intestine.

Coming soon... Alternates to PPIs and natural assistance with GERD.

Note: This is not to be used as medical advice, please see you healthcare professional when treating your child for any condition.

Friday, April 16, 2010

Birth Experience

Being pregnant for the first time is all about firsts, most notably so, your first labor experience. Girlfriends with children told me, its only max one full day of your life, compared to how long you've been pregnant, its really nothing. This helped me in only one way, I had no anxiety about going into labor. I did not write a specific birth plan, but I knew how I wanted it to go. Preferably no pain meds, including epidural, no induction. Just keep it as natural as possible. For my last 4 weekly visits to the OB, baby was "locked and loaded" as I liked to say. The 2 visits before my due date, they asked if I would like my membranes stripped, which after some research, I declined. I didn't want to speed up the onset of my labor (it being my first I was anxious about having a real live baby to care for).

The night of due date, early labor started and I was able to go to bed. Starting at 1am the contractions were strong enough to keep me up. I woke my boyfriend up at about 3, and by 5am, we were on the way to the hospital. My contractions were about 4-5 minutes apart.
At 7am I was 5-6cm dilated and 100% effaced. It seemed things were moving along quickly. The rest of the day went something like this:
-10am still 5-6cm, they want to break my water. I decide to wait.
-12pm still 5-6cm, I agree to let them break my water.
-2pm 8cm, contractions are very strong, and I am involuntarily baring down.
-4pm still 8cm, my baring down has caused my cervix to swell. I am told I need an epidural in order for the labor to proceed due to the swelling/baring down situation. I reluctantly agree.
-4:30pm I wonder why I didn't have an epidural the whole time! I was feeling great.
-5pm 10cm!! We can start the pushing process. The epidural has made it so I don't have the urge to bare down. I push based on sensing my contractions.
-6pm my contractions have slowed down, they load me with pitocin to increase the frequency and strength of my contractions.
-7:30pm still pushing, they make an attempt with a vacuum pump, which becomes unsuctioned as the doctor pulls with all her might and blood splatters on everyone, including my terrified boyfriend.
-7:40pm they try to vacuum baby out again. Not ok at this point, as it is another massive fail.
-7:50pm doctor tells me I need to have a c-section as I am not delivering vaginally.
-8:10pm baby boy is born via c-section.

As it turns out, the babies head was turned just slightly to the side and during my delivery I was pushing out not the crown, by the side of his head (which looked awfully mutilated after all the pushing and vacuuming). In that position it would have been impossible to vaginally deliver him.

So basically, everything I didn't want to happen, happened. I could not believe that after 17 hours of labor and 2.5 hours pushing I end up having major abdominal surgery to deliver my baby. I felt defeated. The whole experience was so far from ideal that I am officially traumatized (even up until writing this I forgot about the several times I vomited during labor!)

Friends told me, don't dwell on it, look what you have a healthy baby boy, etc. Ok fine, I will admit its hard to be mad when you have a little bundle of joy. But as I am still recovering, nearly 6 weeks after the fact, rehashing the memories of labor can still bring tears to my eyes.

Looking back, I would have never let them break my water. That was the first mistake by which I think the rest became inevitable. Perhaps my body knew the baby was slightly turned and not ready to come out. Its anyone's guess, but I was very disappointed with the whole process, and will have a forever anxiety about childbirth from now on. How was your experience? Is this typical of first babies, or can this happen with any childbirth? Just wanted to share my experience, and find out yours.