Andersen Baby's Tummy Troubles: October 2013

Thursday, October 31, 2013

Acid Dump, or why nighttime Delayed Release PPI dose should be given before 530PM

Dr. Phillips (creator of Zegerid and head of the former MARCI Kids) wrote this. Copying from a hard to find post on a BabyCenter forum.

SoluTab and any of the delayed release PPIs do not work at nighttime very well. Let me clarify, from 9 pm till about 2 am there is very little acid production (this is because of ancient genetic encoding). Ate the evening meal while day light 6pm or so, then go to sleep (then acid kicks in in early am (~2 am to 6 am) to kill any bacteria that were ingested). This remnant genetic predisposition is still with us. What do PPIs require to work??? (Answer: Actively secreting acid pumps). How long is the PPI in your babies system? (for approx 120 minutes after you give it). If the acid pumps (proton pumps) are not on during that time period then acid will not be blocked. Immediate release PPIs (such as Zegerid or BuferBabies/PPI) have a buffer in them and that turns on the acid pumps (in addition to protecting the PPI from acid degradation). So Immediate acting PPIs can be given without regard to meals (or even in the bottle)

Delayed release PPI such as Prevacid OTC need to have active acid secreting cells ("pumping") in order to block the pumps. The body shuts down pumps after 7 pm to ~3am. If you give the delayed release Prevacid, then it will be in the baby's body for 3.5 to 4 hrs after administration, then it will be gone. SO if you give the PPI after 5:30 it will have no effect because no pumps will be on while the Prevacid is in the bloodstream.

It is simple really, PPI drugs (such as SoluTab) can only block pumps that are in place and ready to make acid.

Well it is really quite interesting. The acid pumps are finite (meaning there are only so many available in a 24 hr period). When you use a buffer and immediate release PPI - the buffer hits the stomach and raises the pH. This makes the stomach lining send a signal to the acid secreting cells (parietal cells) to wake the pumps and get some of them making acid just a the PPI part hit the pumps and shuts them down. When you use a buffer, a lot of these pumps get used up. Therefore, by giving a dose around 8 or 9pm, or thereabouts, the pumps are exhausted and there aren't any to come on in the 2am period - so then there is no acid dump.

the SoluTab contains Prevacid in enteric-coated granules (inside the SoluTab). The medicine (lansoprazole) is absorbed in 1.5 hrs and the amt of time it is in the system is 120 minutes. So approx 3.5 hrs after a dose there is no drug in the system to block the acid pumps (called proton pumps). The nighttime acid begins at 2am and continues till 7 am (roughly). So, if you give a dose at 5:30pm then it is gone at 9pm (way before the acid pumps start making the nighttime acid).

Immediate release PPIs (such as Zegerid, BufferBabies, CaraCream) has a buffer that stimulates those pumps to come on (that would have come on from 2 am till ~7am) and then blocks them while they are on.

Wednesday afternoon: Slept from 2 to 3, squirmed and sucked on the hand she was able to get out of the swaddle until 330. Sat with me at the computer until 4, crying and then screaming. Intermittent screaming since. Fell asleep at 730, put her in bed at 8. Woke right up. Screamed with Dave until 10, slept w/pcifier until 11, ate at midnight, fell asleep on me at 115, slept in raised bassinet until 330. Had a BM at 330. Looked normal.
Then 430AM-10AM. Very quiet. I don't think she was pain free; I think she was too tired to fight sleep anymore. No more meds as of this afternoon to see if stomach pain diminishes off simethicone and PPI.

Thursday: no real naps. Slept a bit in car, in my arms, and in her carseat in the cart at the store. Lots of screaming, especially in the evening. Straightens legs when she does. Hiccups, gasping, etc. Ate at 715pm. Diarrhea diaper at around 730PM. No real issues taking bottles. After an hour-plus of screaming (7-815 with a quiet time during her diaper change) we gave Rolaids liquid which provided relief (hyoscyamine at 745 did nothing), so acid seems to be the big problem. Fell asleep at 830pm, finally spit out pacifier at 920.

Wednesday, October 30, 2013

Put her down at 1115, was awake by 1120. Tried going back on her own. Something is still keeping her up, some sort of pain or discomfort. Sitting up fully against me seems to help her stomach pain, sometimes. Lots of burps against me now (fermentation in stomach?? she ate 2 hours ago). Now she is screaming in my arms. Literal screaming. It stops when stomach has pressure on it (when laying on stomach) but she has a hard time sleeping that way.

Someone on the Facebook group suggested Zegerid is the problem because of the sodium bicarbonate. I'm slow to believe that because Simon had the same problem and he was never on Zegerid (he was on Prevacid solutabs).

I just ordered digestive enzymes; they should be here November 1st. Source Naturals Essential Enzymes 500 Mg.

Another sleep of 3.5 hours. Night 15 on the compound then is as follows:

1130-1215 (45 minutes -- about 1 sleep cycle)
1-430 (3.5 hours)
6-930 (3.5 hours)

I probably could have gotten her down sooner but I was convinced she would wake up. Both the 1215 and 430AM wake-ups were low on crying and squirming. Nora returned to sleep peacefully.

This morning she is passing gas while eating - could it be the probiotic? I will give a half capsule with her next bottle. It may be (knock on wood) helping her tummy, after all.

The gas she passed turned out to be a small BM. Yellowish, "normal" stool.

The real test will be seeing how she naps today.

5AM Nora had daily BM. Looked less sticky (probiotics cleaning out the intestines?) and slightly more formed, also less uniform. Some seedy bits where before there were none. Also didn't smell quite as bad (but I have a cold so who knows). No problems passing it.

Sleep has been bad. 1130PM to 1215AM, and 115AM to 445AM. That 3 1/2 hour stretch is the longest she's had in 2 days. Could be exhaustion, but at 1215 when she fell asleep there was no stomach pain, no kicking and screaming. None now either, at 530. There are, however, some reflux signs: squirming and turning head, and gasping.

I'm now hearing about a natural "acid dump" that occurs in the middle of the night. Could this be what's eliminating the stomach pain? Or are the probiotics starting to work? OR is she just too exhausted to fight it? Only time will tell.

Trying to chronicle my third baby's digestive issues so I know better how to treat them and those of subsequent children (the first two had tgis as well, it was never fully understood or controlled). If it helps someone else, all the better.

Acid reflux symptoms manifested at approximately 3 weeks of age. Went to doctor shortlly thereafter, was prescribed Prevacid solutabs, 7.5 once a day. Knew it wouldn't be enough. Did it twice a day. Began to see results after a week. Doctor refused to up dosage to that amount. Was forced to switch to omeprazole/Zegerid/MCS homemade compound. Started to work after 4-5 days, then rapid decrease in sleep and comfort level. Acid production started to decrease again by day 12 but with it came an increase in stomach pain.

Some reflux symptoms such as gasping, head turning from side to side (possible Sandifer Syndrome), inability to sleep for prolonged periods, still present, especially noticeable during the day. At night stomach pain becomes apparent. Legs drawn into chest, screaming, screaming accompanied by some grunting when stomach is massaged. Very little gas is passed. Sleep is sporadic and short lived at best right now.

Bowel movement is pasty and grayish colored (from the compounded medication) but otherwise normal. BM occurs same time every day at approximately 7AM. Baby has no trouble passing BM. No mucus or blood present.

No noticeable stomach pain before day 12 on compounded PPI.

Currently on...
Gerber Soothe formula (probiotic in powder)
Mylicon drops in every bottle (doesn't seem to be helping)
Omep/Zeg/MCS compound at 2mg/ml, 3.5ml (7mg) 3xs a day as per MARCI kids dosing guidelines/suggestion

Day 14 started adding in extra probiotic (brand name to come soon, need to check)

Researching digestive enzymes, may add those into regimen a few times a day
Reading that low acid can cause lack of enzymes, which would make sense with the schedule of symptoms (stomach pain not apparent until acid reflux starts to diminish).
Klaire Labs has hypoallergenic enzymes but out of stock
May try GNC brand although contains dairy and soy

My kids seem to have these problems regardless of what formula they're on. Need to look beyond the formula if we can.

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What's working for Nora

We figured it out so much quicker with this baby than we ever did with our first two. She is now an incredibly pleasant, and dare I say easy, baby. Here's what's working for Baby Nora:

Gerber Goodstart Soothe formula

KlaireLabs Ther-Biotic infant probiotic, 1/4 tsp in morning bottle (work up to this much - start with 1/8 tsp.

OTC lansoprazole capsules, 10mg 3x's a day, changed to 15mg 2x's a day for convenience (this is trial and error; some babies need the three doses so I'd start with that first)

Rolaids liquid antacid (1-2ml) for flare-ups (which are almost 100% GONE!)

Bassinet placed on an incline (front wheels locked and placed inside my husband's work boots, which were then placed on top of a few large books)

Medication information

H2 blockers (ranitidine, Zantac, Pepcid, Axid) are often used for mild acid reflux. They can be given with food. They are VERY weight sensitive and will need to be increased as your child gets bigger. They have a tendency to stop working altogether after a few weeks. A way to prevent this might be not to use it all the time. If your baby needs constant treatment, I suggest looking into a PPI.

PPIs (omeprazole - Prilosec or Zegerid, lansoprazole - Prevacid, Nexium) are proton pump inhibitors. They are, in my opinion, very safe and effective. In babies they are often prescribed twice a day, because younger children metabolize the medication faster than adults. They are available in capsule, suspension, powder (that you make into a suspension) or solutab (which is meant to dissolve quickly on the tongue). Except in the case of Zegerid, these medications are delayed-release, which means they need to be given on an empty stomach (more than 2 hours after the last bottle, usually, in babies) and then 30-90 minutes need to go by before baby is fed. This allows the drug to be absorbed before the acid pumps are activated by food. The drug essentially temporarily paralyzes some of the pumps and limits acid production. H2 BLOCKERS AND PPI'S NEED TO BE GIVEN 4 HOURS OR MORE APART FROM ONE ANOTHER, IF GIVING BOTH.

Liquid antacids (Mylanta Cherry Supreme - discontinued/recalled since 2010), CVS brand cherry antacid, Rolaids) are effective for occasional flare-ups. Aluminum free is the only kind I will give my children. Rolaids came out with one in the fall of 2013 (right in time for Nora) that is easily procured in the United States at most supermarkets. Liquid antacids can cause loose stools because of the magnesium. They are not meant to be used long-term, only until the H2 blocker and/or PPI start working. They are wonderful for the middle of the night when baby can't settle back down and isn't yet due for another dose of her other medication. LIQUID ANTACIDS SHOULD NOT BE GIVEN WITHIN AN HOUR OF A PPI DOSE. THEY CAN BE GIVEN WITH AN H2 BLOCKER WITHOUT ANY PROBLEMS.

IF YOUR BABY IS STILL HAVING ACID FLARE-UPS, THEIR MEDICATION MOST LIKELY NEEDS TO BE ADJUSTED.

Disclaimer: I am not a medical professional. I make no absolute claims on the veracity of my information, nor do I guarantee that you will see the same results we did. Your mileage may vary.