Perhaps my theory is full of water, but this seasoned pediatrician’s belief is that the price that modern society has paid for the successful ‘back to sleep‘ campaign has been an increased incidence of gastro-esophageal reflux (GERD). The practice was introduced to Western medicine at the end of the last century, to reduce Sudden Infant Death Syndrome (SIDS).
When newborns are kept solely on their backs, acid, mucus and food may be more likely to slosh all the way up to the back of the throat, eventually leading to the tubes that are supposed to drain to the middle ear. That has led to an increasing number of infections (otitis media), and an explosion of antibiotic use in very young children.
So, is it the reflux, the treatment of the reflux, the consequences of the reflux, or the treatment of those consequences that increases an infant’s risk of developing signs and symptoms? Aggressive behaviors, hyperactivity, lack of focus, sensory issues, and various gut disorders are commonly ascribed to ASD. Such are the complications woven into the stories of many parents interviewed at The Child Development Center.
The practice of placing children on their back was based on observations in other countries, and theories about characteristic electro-encephalographic patterns characterizing those with increased risk of SIDS. Studies in the Netherlands confirmed the observation, and led to the AAP recommendations. No doubt, this strategy has worked for SIDS. However, could the emphasis on alteration of those sleep patterns – related to breathing – have a non-intended effect on other CNS development, as well?
Subsequent research has confirmed the increase in reflux related to infant positioning. The knee-jerk reaction by modern pediatricians has been the issuance of an Rx for antacids, in some form, from Tums to Nexium. Vitamin and mineral absorption becomes impaired. I have previously documented the pitfalls of this intervention.
This week, JAMA reported that, “… infants prescribed antacids to manage acid reflux, or spitting up, under age 1 had more bone fractures later in childhood.” Calcium absorption is believed to be the culprit. “There was a dose-response relationship between fracture hazard and duration of treatment with PPIs. Those taking them for a month or less were at a 19% greater hazard of bone breakage than infants who did not take the suppressors. Those taking the drugs for 60 days to 150 days were at 23% greater hazard and those taking them longer than 150 days were at 42% increased hazard.”
The medical establishment altered the environment in the 1990s when we repositioned babies. Consequences have included plagiocephaly (flat head), torticollis (tight neck), and feeding difficulties. Then, we re-set the field again with antacid preparations. Present literature warning about these pharmaceuticals is probably just the tip of the iceberg.
Environmental change + Susceptible Individual = Alteration from Expected Norm
As a practicing neonatologist, nearly all of our ‘premies’ suffered up-chucking of some sort. I never ordered Prevacid, Zantac, Pantaprozole, etc. in the last century – it wasn’t available. Assiduous positioning and a small amount of Bethanecol (a drug to increase gastric tone) worked great. Ear infections in the first years of life were rare, and doctors seldom resorted to antibiotics. And, we didn’t see much autism in the follow-up clinics.
The Safe to Sleep® campaign offers lots of useful advice. SIDS has decreased by 50%. Some common sense is needed, however. For example, it probably is not necessary to stress the ‘supine position only’. Babies will usually drift to their sides, anyway, especially as they get older. And, if a responsible person is close, it’s pretty safe.
When reflux is diagnosed, simple positioning and an appropriate evaluation should precede any intervention that involves medication. If recurrent infections appear, the placement of ears tubes can mitigate the requirement for further rounds of drugs.
Is it really necessary to keep all infants on their back, all of the time? The ramifications of this policy need to be re-examined, as they may apply to the epidemic number of children with autism.