Proton pump inhibitor (PPI) selection and administration in children

Choice of PPI
Under 1 year old	1 year old and over
ORAL ROUTE
First line: Omeprazole orodispersible tablets or capsules Unlicensed < 1 year and < 10kg	First line: Omeprazole orodispersible tablets or capsules Licensed from 1 year and ≥ 10kg
Second Line: Omeprazole suspension Licensed from 1 month At 1 year switch to omeprazole orodispersible tablets or capsules	Second line: Esomeprazole granules Licensed from 1 year
(If suspension not tolerated) Third line: Omeprazole solution Aclomep^® 20mg/5ml (unlicensed special) Specialist recommendation only	Third line: Lansoprazole orodispersible tablets, capsules Not licensed in children

ENTERAL TUBE (6Fr gauge or larger) includes NG and PEG tubes

First line: Omeprazole suspension

At 1 year switch to esomeprazole granules

First line: Esomeprazole granules

Licensed from 1 year

Second line: Lansoprazole orodispersible tablets (Zoton Fastabs^®)

Not licensed for use in children
Caution with narrow bore tubes

Third line: Omeprazole solution

Aclomep^® 20mg/5ml (unlicensed special)
Specialist recommendation only

ENTERAL TUBE (less than 6Fr gauge) includes gastro-jejunal, naso-jejunal, or if suspension is problematic

First line: Omeprazole solution

Aclomep^® 20mg/5ml (unlicensed special)
Specialist recommendation only

For dosing and licensing information, see: BNFC, the Manufacturer's Summary of Product Characteristics (emc) and/or pharmacy.

Notes:

Omeprazole suspension is the only PPI licensed for use in children under 1 year of age. It is available in two strengths and the most cost-effective strength should be prescribed (consider dose, pack size and in-use expiry). Parents/carers should be counselled of any change of dose/strength.
Other omeprazole preparations are licensed for children over 1 year of age and 10kg or more. These may be used off-label, if they are deemed to be more appropriate, depending on individual circumstances.
Where there is a need for continued PPI use, preparation choice should be reviewed once the child reaches 1 year of age and weighs 10kg or more, or sooner if clinically indicated. If long-term use is anticipated, the need for review should be discussed with parent/carer at initial prescribing of suspension.
Esomeprazole granules are the first line option for enteral tube administration in children 1 year of age or older unless there are repeated problems with administration via enteral feeding tube using the method described in the administration leaflet (below), or an option involving a smaller volume is required. It may be used off-label in some children under 1 year of age, depending on individual circumstances.

Approximate Equivalent doses of Proton Pump Inhibitors

Proton Pump Inhibitor	Equivalent dose
Omeprazole	20mg
Lansoprazole	30mg
Esomeprazole	10mg

Patient information leaflet: Difficulty swallowing capsules/tablets

Parents should be given a copy of this guidance.
For printable version of the leaflet, click here.

Omeprazole capsules/orodispersible tablets

Use the dispersible tablets for part doses.
Round the dose to the nearest quarter of a 10mg or 20mg tablet. Cut the tablet and disperse in a small amount of water, fruit juice or applesauce for oral administration. DO NOT mix with milk or carbonated water.
Patients/carers should be advised that the dispersion should be given immediately (or within 15 minutes).
Tablets are not scored so dose will be approximate.
For the full 10mg or 20mg oral dose the capsules can be opened and the contents dispersed in water or sprinkled on soft food such as yoghurt.

Lansoprazole 15mg and 30mg capsules/dispersible tablets.

Use the dispersible tablets for part doses.
Round the dose to the nearest quarter of a 15mg or 30mg tablet. The tablet should be cut as appropriate for the prescribed dose. Tablets are not scored so dose will be approximate.
Lansoprazole orodispersible tablets are fruit flavoured and should be placed on the tongue and gently sucked. The tablet rapidly disperses in the mouth. Alternatively, the tablet can be dispersed in a small amount of water for oral administration.
For full 15mg or 30mg oral dose, the capsules can be opened and the granules mixed with a small amount of water, apple/tomato juice or sprinkled onto a small amount of soft food (eg yoghurt, apple puree) to ease administration. The mixture should be administered immediately. It is recommended that lansoprazole is given at least 30 minutes before food.
For enteral tube administration use Zoton Fastab^®. (The diameter of the micro-granules varies with brand used). The prescribed dose should be dispersed in at least 10mL water and the tube flushed well afterwards.

Esomeprazole 10mg gastro resistant granules for suspension (sachets)

For a 10mg dose, add the contents of ONE 10mg sachet into 15mL of water
For a 20mg dose, add the contents of TWO 10mg sachets into 30mL of water
Stir
Leave for at least 2 minutes to thicken. This is essential for the granules to disperse fully.
Stir again.
Draw the suspension into an enteral syringe.
Administer through the enteric tube, French size 6 or larger within 30 minutes of reconstitution.
Refill the enteral syringe with a small amount of water and administer (this will rinse the enteral syringe and ensure that the total dose is administered)
Shake and flush any remaining contents from the enteric tube into the stomach. Any unused suspension should be discarded. Up to a 50mL volume of water is recommended for jejunal tube administration at any one time.

Note that it is essential to leave the granules sitting in the water for a few minutes in order for the granules to disperse fully to reduce the risk of blocking the enteric tube.

Glossary

Abbreviation	Meaning
NG	Naso-gastric (tube)
PEG	Percutaneous endoscopic gastrostomy (tube)
PPI	Proton pump inhibitor

Editorial Information

Last reviewed: 30 June 2021

Next review: 30 June 2024

Author(s): Lead Pharmacist, Women and Child Health.

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Lead Pharmacist, Women and Child Health

Document Id: TAM475