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Report: Prescriptions for northern New England kids vary widely

Children in and around Franklin are prescribed acid suppressants at more than twice the rate of children in other parts of New Hampshire despite research showing no benefits from the drugs in infants, the patients most commonly receiving the drugs.

More than 3.3 percent of children in Franklin received a prescription for acid suppressants; in the Lebanon and Peterborough areas, fewer than 1.5 percent of children received such a prescription, according to a report released last week by Dartmouth College researchers.

The majority of infants aren’t suffering from heartburn, doctors and experts said yesterday.

“We could do a better job at educating parents and families about what’s normal for babies. . . . Spitting up is normal,” said Carole Allen, the New England region representative to the American Academy of Pediatrics and a recently retired pediatrician from Massachusetts.

“It might not be good for your laundry bill, but it’s not going to harm anybody as long as they are gaining weight and thriving.”

The report, the first by the Dartmouth Atlas to examine pediatric care, looked at variations in several areas of pediatric care across northern New England, using data gathered by the states of Maine, New Hampshire and Vermont.

The data shows that in one Maine community, 3.6 percent of children received a prescription for an acid suppressant, while on the other end of the spectrum, only 1.2 percent of children in one Vermont community did.

The regional average was 2.3 percent.

“There are two things to keep in mind with that data: It is a high rate and we see the highest rate in infants under the age of 1,” said Nancy Morden, an associate professor at the Geisel School of Medicine at Dartmouth College and one of the study’s authors.

“In that age group there is good evidence that almost all of this drug use is unwarranted.”

A 2011 article published in the Journal of Pediatrics found infant use of prescription acid suppressants “rocketed” between 1999 and 2004. One of the drugs, “available in a child-friendly liquid formulation, saw a 16-fold increase in use during that six-year period,” according to that article.

“These data would imply that somehow the diagnosis of (acid reflux) has been missed over the past several decades or has recently become a major scourge of infants in the developed world, with acid suppressing drugs becoming a new essential food group in their own right,” the author wrote.

The article noted two studies showing the drugs had no better effect than placebos.

The increase in acid suppressant prescriptions “has come about for several reasons, none based in medical science,” the author wrote.

One of those unscientific reasons may be parental requests, said Allen.

Before she retired two years ago, she found more and more parents were asking for acid suppressants for their babies, who were spitting up and crying.

Her own grandchildren were on the medication, she said. She didn’t prescribe it to them, but she didn’t tell her children to take them off of it, either.

“It’s a very difficult call to make when children are spitting up, if they seem to be in pain, but there are plenty of reasons for babies to cry, and babies do spit up,” she said.

Morden agreed: “What we are treating is physiologic; it’s a natural process. Infants have natural gastroesphogeal reflux, and with time and with growing and with age those issues will resolve,” she said.

“Should (overuse) be a concern to parents? I think it should,” she said. “We need to be very honest and open with families about the evidence, and the evidence suggests the overwhelming majority of use here is unwarranted.”

It’s much harder to interpret the data about other prescriptions written for children, Morden and others said.

Are nearly 5 percent of children in Claremont, but only 2.1 percent in Rumford, Maine, in need of antidepressants?

Do 7.7 percent of children in New London need to be medicated for Attention Deficit Hyperactivity Disorder, compared with 4.4 percent of children in Colebrook?

“There’s no evidence the true prevalence of disease is different from region to region,” Morden said. “I don’t know what the right amount is, but we adjusted for Medicaid enrollment and for age and for gender, and that suggests that practice patterns are driving it.”

Access also likely drives much of the variation, doctors said.

“One of the long-held principles of the Dartmouth Atlas has been if you have more of a service available in an area, it will be used more: If you build it, they will come,” said Travis Harker, a family physician at the Family Health Center in Concord.

In the Connecticut River Valley, rates of antidepressant use were significantly higher than in other areas of the state. Does that mean more children suffer from depression there, or that children who suffer from depression in the North Country, where rates are lower, don’t have access to medication they need?

“In the North Country, we have a shortage of workers, a dearth of doctors, nurses and services. If you find a community with a really low number of prescriptions being written, I’d want to ask what’s happening? Are they less depressed, or are they underserved?” Harker said. “The Atlas doesn’t answer these questions; it just tells us where to start asking.”

Similarly, the report doesn’t answer why only 27 percent of children in Townsend, Vt., received antibiotics in an average year, while 42 percent of children in Franklin did.

Bill Storo, chairman of the pediatrics department at Dartmouth-Hitchcock Concord, suggested access is likely behind some of that variation, too.

And, as with acid suppressants, some medical providers may be subjected to more parental requests for antibiotics, he said.

“The main infections of childhood are ear infections, sinus infections, pneumonia, urinary tract infections and strep throat,” Storo said. “But most sore throats aren’t strep, most colds aren’t pneumonia, most earaches aren’t infections, so antibiotics aren’t going to be beneficial. . . . But in families with two working parents, they want to get back to work quickly and they want their child back in school quickly. They’re wanting something to do.

“The flip side is, if it doesn’t have a great benefit and carries some risk, we need to be cautious.”

Statistically, the variations in antibiotic-prescribing practices were less dramatic than for other medications, likely because physicians have been talking about those risks for a long time, Morden said.

“Antibiotics have been for decades the subject of treatment guidelines, quality measures and articles in many publications about overuse. So for decades we’ve had a very good and honest discussion about these medications,” she said. “We really need to have some open and honest discussions about how we use other medications now.”

Allen, formerly the director of pediatrics at Harvard Vanguard Medical Associates in Somerville, Mass., agreed.

“I especially liked in the study when they talked about shared decision-making. That is crucial,” she said.

“Parents should request and insist on it. They need to be included and teenagers also should be included. In the process of arriving at a diagnosis and a prescription, have a back-and-forth and as much information as possible.”

(Sarah Palermo can be reached at 369-3322 or or on Twitter @SPalermoNews.)

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