Management of PPI Dosing and Metoclopramide Use in Pediatric GERD with Chronic Cough
Do not use PPIs or metoclopramide solely for chronic cough unless clear gastrointestinal GERD symptoms are present (recurrent regurgitation, heartburn, or epigastric pain), and even then, acid suppression should not be used for the cough itself. 1
Critical First Step: Determine if GERD Treatment is Indicated
PPIs should NOT be prescribed when there are no clinical features of GERD. 1, 2 The CHEST guidelines provide Grade 1B evidence that treatment for GERD should be withheld in children with chronic cough who lack gastrointestinal symptoms such as recurrent regurgitation, dystonic neck posturing (in infants), or heartburn/epigastric pain (in older children). 1
Key Evidence Against Empiric Treatment:
- Meta-analysis of randomized controlled trials showed no benefit of GERD interventions versus placebo for cough resolution (OR 1.14; 95% CI 0.45-2.93). 1
- PPIs caused increased serious adverse events compared to placebo, particularly lower respiratory tract infections. 1, 2
- Acid suppressive therapy should not be used solely for chronic cough (Grade 1C recommendation). 1, 3
PPI Dosing When GERD is Confirmed
If gastrointestinal GERD symptoms ARE present, treat according to GERD-specific guidelines for 4-8 weeks maximum, then reevaluate. 1, 2
Treatment Duration and Monitoring:
- PPIs or H2 receptor antagonists should not be used for longer than 4-8 weeks without further evaluation. 1, 2
- The specific PPI dose is age-dependent and should follow pediatric GERD guidelines (not cough guidelines). 1
- Reassess response after the 4-8 week trial period. 1, 2
Age-Specific Considerations:
- For formula-fed infants: Start with non-pharmacologic interventions (reducing feed volumes with increased frequency, feed thickeners, or hydrolyzed formula for 2-4 weeks) before considering PPIs. 1, 2
- For breastfed infants: Consider alginates before PPIs. 1, 2
- PPIs are not recommended for uncomplicated physiologic reflux in infants. 2
Metoclopramide (Reglan) Use: Exercise Extreme Caution
Metoclopramide should generally be avoided as monotherapy and only considered in specific circumstances with careful risk-benefit assessment. 1
When Metoclopramide May Be Considered:
- If esophageal dysmotility is suspected or documented. 4
- If response to PPI alone is inadequate after 4 weeks. 4
- One study showed lansoprazole plus metoclopramide had better response rates than ranitidine plus metoclopramide in neonates resistant to monotherapy. 5
Critical Safety Concerns:
- Metoclopramide carries appreciable risk of central nervous system complications, including extrapyramidal symptoms and tardive dyskinesia. 6
- Despite these risks, substantial numbers of US children use metoclopramide chronically (estimated 28,222-89,020 children). 6
- The FDA has issued warnings about prolonged metoclopramide use in all age groups.
Practical Approach if Metoclopramide is Considered:
- Use only after PPI trial has shown inadequate response. 4
- Limit duration to the same 4-8 week timeframe as PPI therapy. 1
- Monitor closely for neurological adverse effects.
- Consider referral to pediatric gastroenterology before initiating. 3
Common Pitfalls to Avoid
Do not prescribe PPIs for isolated chronic cough without gastrointestinal symptoms—this causes more harm than benefit. 1, 2, 3 The evidence shows:
- No improvement in cough outcomes. 1
- Increased risk of lower respiratory tract infections (OR 6.56; 95% CI 1.18-26.25). 3
- Increased risk of community-acquired pneumonia, gastroenteritis, and candidemia. 2, 3
- Potential for vitamin B12 deficiency and bone fractures with prolonged use. 2, 3
Do not continue acid suppression beyond 4-8 weeks without reevaluation and further diagnostic workup. 1, 2
When to Refer to Pediatric Gastroenterology
Refer if: 3