When you stop using a proton pump inhibitor (PPI) a spike in stomach acid production is pretty likely. So your child may be in pain until stomach acid production normalises. This does not necessarily mean that the wean has failed. You need to consider pain management for the duration of the wean which could be several weeks. Talk to your doctor about appropriate pain management during this time.
For every child started on a proton pump Inhibitor (PPI) such as Omeprazole (Losec) at some point your GP or paediatrician will raise the inevitable question of weaning your child off their medication. For many parents this is a difficult decision to make as they remember what their child was like before their reflux was treated. No-one wants to go back to having a child who doesn’t sleep, eat or want to play.
There are good reasons for wanting to wean. If your child needs to be on a PPI in order to have a normal quality of life then obviously it is needed. Unfortunately your child’s doctors have no way of telling whether or not your child still needs the medication unless you attempt a wean. Over 50% of children will have outgrown their reflux by age one year. Keeping your child on a PPI if they don’t need it also raises concerns, at the moment there is still little data available on the safety of long term PPI use in children. We do however know that in adults PPIs can cause osteoporosis and an increased susceptibility to gastroenteritis and chest infections in chronic use over many years.
So what do you need to know in order to make your weaning attempt as successful as possible. Here mum and GP, Naomi Farragher, explains how PPIs work and what happens when you stop them.
PPIs block the acid pump which exists of the parietal cells in the lining of the stomach, stopping them from being able to pump acid from inside the cell into the stomach. The acidity of the stomach is controlled by three hormones produced by the body in response to a high (non-acidic) pH in the stomach, these hormones act on the parietal cells to make them produce more acid, however in the presence of a PPI it cannot be moved into the stomach. It is thought that whilst on a PPI the body produces high levels of these hormones to try and get more acid to be secreted.
When you stop using a proton pump inhibitor (PPI) at the start there will still be high levels of these hormones acting on the parietal cells getting them to make lots of acid which can now be released into the stomach. Therefore a spike in stomach acid production is inevitable. This is called a rebound acidosis and in many studies this has been shown to be worse after dinner and at night. So your child may show similar signs to the ones they had when they had uncontrolled GORD. This does not necessarily mean that the wean off medication has failed. You need to consider pain management for the duration of the wean which could be several weeks. Talk to your doctor about appropriate pain management during this time. It can take several days for this hormonal response to correct itself and normalise the pH. In the meantime it may cause some inflammation of the lining of the stomach which can take a couple of weeks to settle. This means you won’t be in a position to know if the wean has worked until after the stomach acid normalises and inflammation has resolved.
Of course there are limits and you need to discuss these with your doctor. Consider discussing the use of paracetamol or codeine with your doctor in the intervening period and what the limits of tolerance should be for pain for your child before you restart the PPI.
There is no evidence that a slow wean is beneficial from a number of studies that have been done in this area in adults. Naomi’s advice is to cut the dosage in half for a week then remove while managing with pain relief. A couple of weeks later, the child should be able to manage without pain relief if the wean has been successful. If the pain relief is not working during the weaning process, it may indicate that the child is not yet ready to be weaned, in which case you should consult with your doctor about restarting the PPI.
A word about medication reduction:
All reflux parents would like their child to be able to manage without medication. Somehow though, we often end up tying our child’s “success” or “failure” with a wean to whether or not they are actually “successful” or a “failure” .If a child fails a wean we often as parents see that as a failure on our behalf as well. Success and failure are a bad choice of words. A child (or their parents for that matter) are neither successful or failures if they need medication. They just need it. That’s all. Try to remind yourself that it’s neither your fault or theirs.
To try and keep it objective, it might help to write down symptoms as they occur and when you’ve given medication. This will help you establish any patterns and also to see it as a more objective “trial” rather than the more emotionally-laden, unhelpful terms of “success” and “failure”. At some point most children will be weaned successfully off their medications and continue to be normal, happy, healthy thriving children which is all any of us ever want.
As always, please do not attempt any changes in medication regime without the direction and plan provided by the medical team managing your child. This advice may not be appropriate or safe for your child in your specific circumstances. This advice is provided to inform your discussion with your doctor/s, not circumvent it.
Written by Dr Naomi Farragher, General Practitioner
Reviewed by Dr Looi Ee, MBBS, FRACP, Paediatric Gastroenterologist
Published May 2013