Evidence-Based Review by a Multidisciplinary Team of Pediatricians on the Use of Gastric Acid-Reducing Medications in Children: Indian Perspectives

Abstract

Gastric acid-reducing medications (ARMs) such as proton pump inhibitors (PPIs) and histamine type 2 receptor blockers (H2 blockers) are crucial in pediatric care for treating various gastrointestinal conditions. These medications are frequently used to treat erosive esophagitis, peptic ulcer disease, and gastroesophageal reflux disease (GERD). ARMs are essential to the administration of eosinophilic esophagitis and Helicobacter pylori infection. Additionally, literature also supports its use in alleviating drug-induced dyspepsia, preventing stress-related mucosal damage, and lowering the risk of acid aspiration syndrome during anesthesia in critical care settings. Despite the widespread indications of ARMs, PPIs, the most potent acid suppressants, present concerns regarding safety and their inappropriate use in pediatrics. This paper aims to address these gaps by providing comprehensive, practical recommendations for ARM use in pediatric settings. The methodology involved a structured literature review and opinions from 24 pediatric specialists across India, including neonatologists, general pediatricians, pediatric gastroenterologists, a pediatric hepatologist, pediatric nephrologists, a pediatric pulmonologist, and a pediatric intensivist on the appropriate choice of ARM use in various clinical scenarios. They emphasized the benefits of H2 receptor antagonists (H2RAs) over PPIs, particularly in neonates and infants, where H2RAs offer a safer alternative due to their lower risk of adverse effects. The paper outlines the effective application of H2RAs in managing GERD, preventing stress ulcers, and treating drug-induced dyspepsia. It also provides guidelines for appropriate ARM use, stressing the need for careful patient evaluation to minimize the risk of unnecessary ARM use. Pediatricians also provided a view on the use of H2RAs beyond gastrointestinal indications, such as in urticaria, where they show promising clinical application when combined with H1-antihistamines. This paper offers valuable insights and recommendations for optimizing the use of ARM in pediatric practice. By highlighting the advantages of H2RAs and addressing the limitations and risks associated with PPIs, the paper aims to guide clinicians in making informed, evidence-based decisions. The goal is to improve clinical outcomes, promote the rational use of ARM, and enhance the quality of pediatric care.

Keywords: drug-induced dyspepsia; h2ras; on-demand use; ppis; ranitidine; stress ulcer prophylaxis; urticaria.

Figure 1. Drug-induced dyspepsia severity scoring for most commonly prescribed drugs and combinations in pediatric practice.

Image credit: All authors. Note: Placetamol+ appears twice on the vertical axis. The top label refers to the standard formulation, while the bottom refers to a variant (extended-release).