Several weeks ago I posted three weekly posts (starting 19th July 2013) about this subject and asked the questions –
If most pyloric stenosis (“PS”) babies can be treated medically rather than surgically,
- Why isn’t medical therapy offered and tried more often?
- Why are the medical journals in the “Western” (or “developed world”) so negative and dismissive of medical PS treatment in their research and statistical reports on this subject?
- Why was Eumydrin, a marketed version of the PS-reduction drug atropine methonitrate, taken off the market in 1987 despite its being safely and successfully used throughout the world?
In this post I want to reflect some more on this matter.
1 Professional comment
I emailed these questions to Prof. Dr Ian Rogers, a retired but still active pediatric surgeon and teacher. As always his response was prompt, clear and gracious:
Many thanks for your email…
Eumydrin was the classical traditional way in which atropine (the active ingredient) was administered to babies receiving medical treatment for PS. Eumydrin was the name of the proprietary preparation.
Atropine was used since it is an anti-cholinergic – it acts against the effects of acetyl choline. Acetylcholine is the transmitting substance used by the vagal nerves when they innervate the stomach and the vagus nerve causes the stomach to contract (peristalse) and to secrete acid and pepsin – hence you can see why the early pediatric physicians thought it would be useful – as indeed it was.
Our proposal that hyperacidity is the prime mover in PS makes it easy to understand why Eumydrin works.
Yet dosage was always going to be difficult – these babies vary in weight and the dose should be carefully titrated according to weight. If not – it is easy to overdose and body weight doses were not always used. [The] Best article explaining this is the article by Jacob 1965 in my bibliography.
Atropine also stops the slowing down tonic effect of acetyl choline on heart rate. Hence too much Eumydrin may cause alarming and life threatening tachcardia. I imagine this is the reason it was withdrawn.
Lansoprazole is an ideal antacid treatment with no known side effects.
I shall read you post and add further comments if I may…
PS That [article] contains a lot of PS babies – In Alexandria apparently they do 2-3 a day! I am in contact with the Prof. of Surgery there, Prof. Shehata, and hope to convince him about the great potential merits of Lansoprazole when I go to the World Congress of Pediatric Surgery Berlin October 13th this year. Prof. Dessanti’s work in Italy is proceeding slowly at the moment.
[Dr Rogers added no further comments.]
2 Another voice
During the month since I wrote the three posts mentioned, I have found a newly published article on the use of Atropine sulphate rather than surgery in treating PS.
It is a generous full length report from Saudi Arabia posted on August 28th. This study is based on the treatment results of 28 PS babies, with half managed in each of the two ways. The results were generally in line with those of other reports I have read: surgery came with more immediate complications than medical therapy (2 of the 14) but only ⅔ of those medically treated were able to complete their course successfully: 4 needed surgery and 2 were lost to the study. Despite the concerns that have been mentioned elsewhere and here about the use of atropine, there were no difficulties in treating these 14 babies, although it is again remarked that the drug requires careful use by the parents concerned and its course is lengthy when compared with surgery.
This report concludes:
Although both surgical and medical options are valuable, time-tested treatment modalities in the treatment of infantile hypertrophic pyloric stenosis, surgery is still the standard treatment worldwide. We consider that surgery is superior to medical treatment; however, there is a place for medical treatment in the management of pyloric stenosis, such as contraindication to surgery and parents’ choice of a non-surgical modality. Parents’ compliance with follow-up of medical treatment is, however, mandatory for a good response to treatment.
This report is significant in that it comes from a non-Western country but tables findings and conclusions which generally agree with most others I have read.
3 Some of my own observations
- In recent months I have read several reports actually making mention of medical treatment being raised and discussed by the parents of a PS infant with their doctors!
It is too early to regard these mentions as straws in the wind, but I would like to think that in at least some minds and cases, surgery is no longer regarded as the only option, although it remains the “standard” and “preferred” course.
At this stage the questions will need to be raised by informed parents on behalf of their child and reflecting their own concerns; I have yet to read a parents’ report saying that their pediatric specialist raised with them the option of trying medical treatment.
- One day very soon I would very much like to discover a study of the long-term effects of each course of treatment!
Whilst I recognise that many of the reported, suspected and long-term effects of PS surgery may be difficult to link conclusively with the condition or its surgery, enough work has already been done and reported on here to make it clear that there is considerable reason for concern. The widely quoted statement that “PS and its surgery have no long-term effects” is a blatant lie or based on unacceptable ignorance.
- I am concerned that the withdrawal of the drug Eumydin is yet another sign of our litigious disease and the development of the “nanny-state”. I am aware of what Dr Rogers mentioned above: that atropine compounds have side-effects which must be carefully managed. But I have not read of any PS baby dying because of this drug.
I do know that opportunistic and greedy parents supported by avaricious lawyers increasingly seek to exploit considered, responsible and safe attempts to avoid the many hazards of unnecessary infant surgery. One result is that companies withdraw proven and useful choices for fear of financial consequences. Another is that risk insurance is doing much to take the cost of medical care beyond the reach of many people.
- Dr Ian Rogers gets my continued gratitude and respect for his advocacy of the cause of PS, and thereby underlining and advocating the choice of medical treatment as the preferred course for the majority of cases.