What is the recommended tapering strategy for pediatric patients on Proton Pump Inhibitors (PPIs) for Gastroesophageal Reflux Disease (GERD)?

PPI Tapering Strategy for Pediatric GERD

After 8-12 weeks of successful PPI therapy in pediatric patients with GERD, discontinue the PPI abruptly rather than tapering, as the American Academy of Pediatrics guidelines recommend observation after discontinuation to monitor for symptom relapse. 1

Treatment Duration Before Discontinuation

• Initial PPI trial should last 2 weeks to assess response 1
• If symptoms improve, continue PPI for 8-12 weeks total 1
• If no improvement after 2 weeks, discontinue immediately and reassess the diagnosis 1
• Maximum duration should be 4-8 weeks without further evaluation in infants 2

Discontinuation Strategy

The American Academy of Pediatrics algorithm shows direct discontinuation without gradual tapering:

• Stop the PPI completely after the 8-12 week treatment course 1
• Monitor for symptom relapse during observation period 1
• If symptoms relapse after discontinuation, refer to pediatric gastroenterology rather than restarting empirical therapy 1

Why Abrupt Discontinuation is Recommended

• Pediatric guidelines do not include tapering protocols, unlike adult practice 1
• The goal is to identify patients who truly need ongoing therapy versus those with physiologic reflux 1
• Rebound acid hypersecretion is a concern in adults but is not emphasized in pediatric guidelines 3

Critical Age-Specific Considerations

For Infants (<1 year)

• PPIs should generally be avoided in infants due to lack of efficacy and increased infection risk 2, 4
• If used off-label for severe refractory GERD, limit duration to 4-8 weeks maximum 2
• Discontinue immediately if no clear benefit is observed 2
• Increased risk of lower respiratory tract infections, gastroenteritis, and candidemia with PPI use in this age group 1, 2

For Children ≥1 Year

• FDA-approved PPIs (omeprazole, lansoprazole, esomeprazole) can be used with appropriate indication 5
• Follow the 8-12 week treatment course before discontinuation 1
• Ensure clear GERD features exist (heartburn, epigastric pain, weight loss, erosive esophagitis) before initiating therapy 5

Post-Discontinuation Management

After stopping the PPI:

• Observe for symptom recurrence during follow-up visits 1
• If symptoms relapse, refer to pediatric gastroenterology for further evaluation 1
• Consider alternative diagnoses such as eosinophilic esophagitis, cyclic vomiting, rumination, or gastroparesis if PPI was ineffective 1
• Reinforce lifestyle modifications including dietary changes, smaller meals, and positional therapy 5

Common Pitfalls to Avoid

• Do not continue PPIs indefinitely without reassessment 5
• Do not restart PPIs empirically for symptom relapse without specialist consultation 1
• Do not use PPIs for uncomplicated physiologic reflux ("happy spitter") 1, 5
• Do not assume gradual tapering is necessary—pediatric guidelines support abrupt discontinuation 1
• Do not use PPIs for chronic cough or respiratory symptoms without clear gastrointestinal features 5

Monitoring During Discontinuation

• Watch for return of heartburn, regurgitation, or feeding difficulties 1
• Monitor weight gain and growth parameters 1
• Assess for warning signs including weight loss, dysphagia, or hematemesis that warrant immediate specialist referral 1