Regionale forskjeller i bruk av protonpumpehemmere hos barn

BACKGROUND

Physiological gastroesophageal reflux in infancy is difficult to distinguish from reflux disease. International guidelines recommend restrictive use of acid suppression therapy for infants due to the lack of documented effect, but its use in infants and older children has increased in recent years. This study aims to describe change over time and geographic variation in the investigation and treatment of suspected gastroesophageal reflux disease.

MATERIAL AND METHOD

In aggregated data from the Norwegian Prescribed Drug Registry for the period 1.1.2007-31.12.2020, we examined regional differences in the number of proton pump inhibitors dispensed for children and adolescents. Data from the Norwegian Patient Registry were analysed to identify the use of 24-hour pH measurement and gastroscopy, which can support the suspicion of gastroesophageal reflux disease.

RESULTS

The number of proton pump inhibitors dispensed in the first year of life increased and was highest in South-Eastern Norway Regional Health Authority, with 10.1 per 1000 children in 2007 and 54.7 per 1000 children in 2020 (relative risk 5.4, 95 % confidence interval 4.6 to 6.4). The number dispensed in 2020 was 64 % higher in South-Eastern Norway Regional Health Authority compared to Northern Norway Regional Health Authority and Central Norway Regional Health Authority. There was little change in the number of gastroscopies, but use of 24-hour pH measurement fell by 52 % from 2016 to 2020.

INTERPRETATION

Use of proton pump inhibitors in infants has increased considerably despite the guidelines. Together with geographic variation, this may point towards overtreatment of physiological reflux in infants. Few investigations indicate that an increasing proportion are treated without supporting diagnostics.

Proton pump inhibitors for infants in three Scandinavian countries increased from 2007-2020 despite international recommendations

AIM

There is weak evidence that proton pump inhibitors (PPIs) alleviate non-specific complaints often attributed to gastroesophageal reflux in infancy and international guidelines do not recommend their use. We studied PPIs dispensed for infants in three Nordic countries.

METHODS

This was an observational population-based study of infants living in Norway, Sweden and Denmark in 2007-2020. We used nationwide pharmaceutical registers to study dispensed PPIs. The data provided a total of 3.3 million observed years on about 240,000 annual births.

RESULTS

The overall use of PPIs in infancy showed a marked increase in all three countries from 2007-2020. In 2020, PPI dispensing was 46.4, 23.4 and 18.9 per 1000 per year in infants aged 0-11 months in Denmark, Norway and Sweden. These were increases of 357%, 585% and 556% respectively. Although the rate was highest in Denmark, it had decreased by 42% in the last three years of the study.

CONCLUSION

Despite international recommendations against routine PPI prescribing in infancy, dispensed PPIs increased more than four-fold on average in three Nordic countries from 2007-2020. The reason for this notable increase could not be established from the data, but the large variations over time, and between the countries, probably indicated unwarranted use.

Ribosomal protein insufficiency and the minute syndrome in Drosophila: a dose-response relationship

Minutes comprise > 50 phenotypically similar mutations scattered throughout the genome of Drosophila, many of which are identified as mutations in ribosomal protein (rp) genes. Common traits of the Minute phenotype are short and thin bristles, slow development, and recessive lethality. By mobilizing a P element inserted in the 5' UTR of M(3)95A, the gene encoding ribosomal protein S3 (RPS3), we have generated two homozygous viable heteroalleles that are partial revertants with respect to the Minute phenotype. Molecular characterization revealed both alleles to be imprecise excisions, leaving 40 and 110 bp, respectively, at the P-element insertion site. The weaker allele (40 bp insert) is associated with a approximately 15% decrease in RPS3 mRNA abundance and displays a moderate Minute phenotype. In the stronger allele (110 bp insert) RPS3 mRNA levels are reduced by approximately 60%, resulting in an extreme Minute phenotype that includes many morphological abnormalities as well as sterility in both males and females due to disruption of early gametogenesis. The results show that there is a correlation between reduced RPS3 mRNA levels and the severity of the Minute phenotype, in which faulty differentiation of somatic tissues and arrest of gametogenesis represent the extreme case. That heteroalleles in M(3)95A can mimic the phenotypic variations that exist between different Minute/rp-gene mutations strongly suggests that all phenotypes primarily are caused by reductions in maximum protein synthesis rates, but that the sensitivity for reduced levels of the individual rp-gene products is different.