What is the recommended tapering schedule for weaning a 6-month-old infant off omeprazole (proton pump inhibitor)?

Weaning Omeprazole in a 6-Month-Old Infant

For a 6-month-old infant on omeprazole, you can discontinue the medication either abruptly or with a gradual taper over 2-6 weeks, as both approaches are reasonable based on adult data extrapolated to pediatrics. 1

Evidence-Based Discontinuation Approach

Tapering vs. Abrupt Discontinuation

The 2022 AGA guidelines on PPI de-prescribing found no significant difference between abrupt discontinuation and a 3-week taper (PPI daily → every other day for 3 weeks → stop) in adults, with 31% vs 22% remaining off PPIs at 6 months respectively. 1 However, this taper may have been too rapid given that parietal cell hyperplasia regression takes 2-6 months. 1

For infants, I recommend a conservative 2-4 week taper to minimize rebound acid hypersecretion (RAHS) symptoms:

• Week 1-2: Continue current dose daily
• Week 3: Give dose every other day
• Week 4: Discontinue completely

Alternatively, abrupt discontinuation is acceptable if the infant has been on omeprazole for a short duration (<8 weeks) or at low doses. 1

Managing Rebound Symptoms

Expected Symptoms After Discontinuation

Infants may experience increased irritability, crying, feeding difficulties, or regurgitation due to rebound acid hypersecretion, which can persist for up to 2 months but typically resolves within 2-6 months as parietal cells normalize. 1

Symptom management strategy:

• Use H2-receptor antagonists (ranitidine alternatives like famotidine) as needed for breakthrough symptoms 1
• Consider antacids (calcium carbonate, magnesium hydroxide) for immediate symptom relief 1
• Avoid immediately restarting continuous PPI therapy unless severe persistent symptoms last >2 months 1

When to Reconsider Discontinuation

Severe persistent symptoms lasting >2 months after PPI discontinuation suggest either:

• A continuing indication for acid suppression exists 1
• A non-acid-mediated cause of symptoms (consider alternative diagnoses) 1

Critical Considerations for Infants

Lack of Pediatric-Specific Data

The evidence for omeprazole weaning in infants is extremely limited. A Cochrane review found very low-certainty evidence that omeprazole provides minimal benefit over placebo in infants 3-12 months old, with cry/fuss time improving similarly in both groups (omeprazole: 246→191 min/day vs placebo: 287→201 min/day). 2 This suggests many infants may not require PPI therapy at all.

Dosing Context

Infants typically receive omeprazole 0.7-2.8 mg/kg/day in divided doses. 3 The majority respond to 0.7-1.05 mg/kg/day, though some require higher doses up to 2.8 mg/kg/day. 3 If your patient is on a higher dose, consider stepping down to a lower dose before complete discontinuation.

Common Pitfalls to Avoid

• Do not restart continuous PPI immediately for mild rebound symptoms—use as-needed H2-blockers or antacids instead 1
• Do not confuse rebound symptoms with true GERD recurrence—rebound typically resolves within 2 months 1
• Do not taper based on concern for PPI-associated adverse events alone—discontinuation should be based on lack of indication, not fear of side effects 1
• Ensure parents understand that temporary worsening of symptoms does not necessarily mean the infant needs to resume PPI therapy 1

Monitoring After Discontinuation

• Assess symptoms weekly for the first month
• If symptoms persist beyond 2 months, consider pH monitoring or endoscopy to determine if true GERD exists requiring ongoing therapy 2, 3
• Most infantile reflux is self-limiting and improves with age, with 50% of infants under 3 months affected but most resolving by 12-18 months 2