An exploration of influences and changes in the diagnosis and management of gastro-oesophageal reflux in infants aged 0-1 year.

Cowie, Jean and Milligan, Christine and Holland, Paula (2020) An exploration of influences and changes in the diagnosis and management of gastro-oesophageal reflux in infants aged 0-1 year. PhD thesis, Lancaster University.

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Abstract

Gastro-oesophageal reflux (GOR) is common in infants. According to NICE (2015), it affects 40% or more of infants and generally resolves naturally without the need for medical treatment. However, preliminary indications suggest that there has been a rise in the use of medicines to manage GOR in young infants under the age of twelve months. This is particularly evident for acid suppressant medicines such as ranitidine and omeprazole – drugs that are currently not licensed for use in the 0-1 age group in the UK (BNFC, 2019). To gain a greater understanding of the extent to which this rise in prescribing rates is manifest in Scotland, and what underpins this shift in prescribing patterns, this thesis adopted a two-stage research approach to the study. Stage one of this study analysed national prescribing data from the Information Services Division of NHS Scotland (ISD), to explore how patterns of prescribing for alginate, domperidone, omeprazole and ranitidine have changed over time, and how they differ between NHS Board areas in Scotland. Findings from stage one confirmed that the prescribing of alginate, omeprazole and ranitidine increased significantly in Scotland over a 7-year period between 2010 and 2016. Prescribing of alginate increased from 15.7 per 100 infants in 2010 to 24.7 per 100 infants in 2016, whilst the prescribing rate for ranitidine increased over four-fold from 2.3 per 100 infants in 2010 to 9.7 per 100 infants in 2016, and for omeprazole the prescribing rate increased over three-fold from 0.9 per 100 infants in 2010 to 3.2 per 100 infants in 2016. Furthermore, the data revealed regional variation in the drugs prescribed. Stage two sought to investigate what underpinned this change in prescribing patterns in greater depth. Focusing on one NHS Board in Scotland that had a high prescribing rate for ranitidine, stage two adopted a qualitative approach and used in-depth interviews to explore issues contributing to this shift in prescribing patterns from the perspectives of health visitors, general practitioners and parents. Semi-structured interview schedules were used to guide in-depth interviews with 22 participants. Issues of adherence to national guidelines, the shift away from conservative to more pharmaceutical treatments for GOR and shifts in knowledge and power between clinicians and parents were explored. While general practitioners and health visitors remain the key players in diagnosing and treating GOR in infants in Scotland, general practitioners often rely on the expertise of health visitors whom they see as the experts in this field, whilst health visitors are often influenced by parental pressures. Parents were thus found to play an important role in influencing the diagnosis and the treatment approach offered, with the prescribing of medicines often seen by parents as the first-line of approach to the treatment of GOR. Parental pressures placed on clinicians was seen to arise from changing attitudes and expectations of parenthood, shifts in family support structures, and the growing accessibility of a wealth of health information from (both reliable and unreliable) sources on the worldwide web, as well as the subtle (and not so subtle) advertising of medicines to manage GOR on social media. These factors all play a key role in the pharmaceuticalisation of treatment for GOR and is likely to go some way toward accounting for changes in prescribing patterns over time. Theoretically, therefore, this study points to the medicalisation of everyday care practices for infants, especially the management of symptoms of GOR. Importantly, it is possible that some infants are being prescribed unlicensed acid suppressant medicines unnecessarily and this has financial implications for the NHS as well as health implications for young infants.