Proton Pump Inhibitors in Pediatric Patients: Indications and Contraindications

Appropriate Use of PPIs in Pediatric Patients

The American Academy of Pediatrics recommends that PPIs are explicitly indicated only for patients with diagnosed gastroesophageal reflux disease (GERD), not for uncomplicated physiologic gastroesophageal reflux (GER) 1, 2
Lifestyle changes should be emphasized as first-line therapy for both GER and GERD before considering medication, as suggested by the American Academy of Pediatrics 1, 2

There is significant concern about the overprescription of acid suppressants, especially PPIs, in the pediatric population, according to the American Academy of Family Physicians 1, 3
Evidence suggests that acid suppression with PPIs may be a risk factor for community-acquired pneumonia, gastroenteritis, and candidemia, as reported by the American Academy of Family Physicians 3
The use of PPIs may also increase the risk of necrotizing enterocolitis in preterm infants, as noted by the American Academy of Family Physicians 4, 5

The American College of Chest Physicians recommends determining if the child has GER or GERD, and implementing conservative measures only for children with GER, while considering PPI therapy for those with confirmed GERD 6
For children with confirmed GERD, the American Academy of Pediatrics suggests starting with lifestyle modifications, and considering PPI therapy for 4-8 weeks, with reevaluation after the treatment period 1, 2, 6

The American College of Chest Physicians advises that PPIs should not be used when there are no clinical features of GERD, and should not be used for longer than 4-8 weeks without further evaluation 6
The American Academy of Family Physicians recommends that PPIs should be discontinued if there is no improvement or symptoms resolve 3, 5

Serious adverse events, particularly lower respiratory tract infections, were significantly higher in PPI-treated infants compared to controls 7
The American Academy of Pediatrics does not explicitly recommend using PPIs for uncomplicated physiologic reflux in infants, however, the guideline society recommends against using PPIs for infants with symptomatic GERD aged one month to less than one year 7

For formula-fed infants with reflux, reducing feed volumes while increasing frequency, using feed thickeners, and trying hydrolyzed milk formula for 2-4 weeks may be considered 7
For breastfed infants, alginates may be tried 7

PPIs should only be used when there are clear signs of GERD, not just reflux 8
If medication is deemed necessary after failure of conservative measures, treatment should be limited to 4-8 weeks with reevaluation 7

Children should be evaluated for documented gastroesophageal reflux disease (GERD) using clinical criteria such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children before considering PPI therapy. 10
The presence of peptic ulcer disease or erosive esophagitis constitutes a clear indication for PPI prescription in the pediatric population. 11
If a child lacks both documented GERD and peptic ulcer disease/erosive esophagitis, PPIs should not be prescribed. 10

The American College of Chest Physicians recommends that PPIs not be used when there are no gastrointestinal clinical features of GERD (Grade 1B recommendation, strong recommendation, moderate‑quality evidence). 10

The recommendation to avoid PPI use without documented GERD is classified as Grade 1B (strong recommendation, moderate quality evidence) by the American College of Chest Physicians. 10