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Should You Use a PPI for Infant Reflux? NO! Here’s Why…

August 31, 2023

Written by Clay Smith

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Proton pump inhibitor (PPI) use in young children is associated with risk of serious infection. It’s best to avoid PPI use in the absence of a very clear indication.

Turns out, stomach acid is good
Gastroesophageal reflux (GER) is physiologic and occurs in 60-70% of children 3 months of age, but some have a more severe presentation. Despite solid evidence, PPIs are increasingly used to treat severe GER (aka GERD, D for disease), but PPI use in children is associated with a host of problems, from increase fracture risk to asthma. Gastric acidity provides protection from pathogens, and altering gastric pH changes the microbiome. Thus, PPIs may increase risk of infection. This was a retrospective French EPI-MERES registry review, with >1.2 million children, median 82 days old. Over half of them had exposure to a PPI (yes, you read that right!). PPI use was statistically and clinically significantly associated with serious infection overall (aHR 1.34; 95%CI 1.32-1.36) as well as specific types of infection: digestive, ear-nose-throat, lower respiratory, urinary, nervous system, both bacterial and viral pathogens (aHRs were all significant, ranging from 1.2 to 1.56). They did a sensitivity analysis to exclude children with H2-receptor blocker use (rarely prescribed in France) and found no difference in the results.

How will this change my practice?
I’m not sure I have ever prescribed PPIs to young children from the ED. Given this association with serious infection, I don’t plan to start without a clear directive from GI.

Proton Pump Inhibitor Use and Risk of Serious Infections in Young Children. JAMA Pediatr. 2023 Aug 14;e232900. doi: 10.1001/jamapediatrics.2023.2900. Online ahead of print.

What are your thoughts?