PPIs could mean “public-private initiatives” which are highly toxic, as recent experience in the UK and in Quebec has shown, but in this case I mean proton pump inhibitors.
Stark CM, Nylund CM. Side Effects and Complications of Proton Pump Inhibitors: A Pediatric Perspective. The Journal of pediatrics. 2015. This excellent and complete review of PPI toxicities has just been published.
Many people seem to think they are safe, and there has been an explosion in their use in the newborn, with practically no supportive data.
PPIs increase :
GI infections (including clostridia)
Upper respiratory infections
Lower respiratory infections
Spontaneous Peritonitis
Coeliac Disease
Gastric Fundal Polyps
Malabsorption of calcium
Malabsorption of magnesium
Probably malabsorption of iron and some vitamins
Acute interstitial nephritis
and, of course, Necrotising Enterocolitis.
You should really have good evidence that gastric acid secretion is causing your baby’s problems before prescribing these toxins.
Neonatal Research 
Keith:
I am trrying to get your review about GER in the Nutrition book that you referred in one of your postings. I guess I have to buy the electronic version of the whole book.
Do you have an opinion or have seen some literature about the use of casein hydrolysate or amino acid based formula for premature infants with the presumed diagnosis of GER?
For what I have found so far there is some information about the incidence of cow milk intolerance (CMI) or allergy (CMA) in infants (0.3 – 7.5%) with symptoms of GER (Host A, Pedatr Allergy Immunol 1994;5 (suppl 5) 1-36).
There are some GI consultants that are suggesting this ‘elimination diet’ approach for preterm infants with significant regurgitation.
I will be interested in your opinion.
Alfonso Pantoja, MD
SJH denver
If you are on researchgate you can get full text of the chapter (https://www.researchgate.net/profile/Keith_Barrington). But I don’t discuss elemental diets in the chapter, as far as I know there is no relevant neonatal data. My (limited) reading of the data in older children is that the evidence is very poor of an effect.
My opinion is
1. Never consult GI for a baby with regurgitation.
2. The only way to clinically diagnose reflux is by seeing regurgitation. There is no other symptom which is more common in children with proven GER than in children without.
3. Many babies regurgitate if they are getting enough feed, its a normal phenomenon.
4. Cow’s milk intolerance or allergy are very uncommon in preterm infants. I have seen maybe 4 definite cases in 35 years of practice, diagnosis requires elimination with resolution followed by a challenge, just like in older children. Resolution of symptoms with elimination is not enough, most babies get better, no matter what you do, so you have to do a challenge to make the diagnosis.
5. There is very little indication for hydrolyzed or elemental formulae in the preterm infant. They have increased osmolarity, so may be associated with NEC.
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