PPI Dosing information. There are different pieces of evidence from the medical literature that suggest different approaches to the dosing of PPI medicines (such as omeprazole, lansoprazole, esomeprazole) in infants (after 4 to 6 weeks of age) and younger children (toddlers) when compared to older children (teens) and adults. Some of the data shows that there is a relationship between age and half-life. Other data does not show this age to half-life relationship. Some data suggests using higher doses and more frequent doses in in infants (after 4 to 6 weeks of age) and younger children and other recommendations are for lower doses, or once a day dosing.
In many cases of GERD in infants and toddlers, your physician/medical team may not want to use a PPI medicine at all and may want to use a medicine such as ranitidine (which is an H2 blocker) or use no medicine at all.
This is why it is very important that you follow your physician/medical teams advice with regard to the treatment of acid reflux disease for your infant/toddler. Also, the information contained on the PPI dosing information page can act as a bridge between PPI dosing in infants and your doctors plan to treat your baby’s reflux.
This PPI dosing information page is to provide information about a study performed at the University of Missouri and became popularly known as MarciKids dosing. This study was done by Jeffrey Phillips Pharm. D (Dr. P) and Marcella Bothwell ENT along with other physicians and nurses. MARCI KIDS (Midwestern Acid Reflux Children’s Institute).
Think of this page as an important reference and tool for you and your professional medical care team if they decide to use a proton pump inhibitor (PPI) and TummyCare Max® which can be supplied by a compound pharmacy.
Some of the information on the PPI dosing information page might sound a little confusing and that is why it’s important to work with your medical care team.
You will need to know your baby’s age and weight. Your baby's age and your baby's weight can be entered into the MarciKids dosing calculator below to assist your medical care team calculate a dose according to the MarciKids data. So don't let all the technical talk scare you.
This information is merely here to give you an understanding of the principles of MarcKids and is intended to provide information only and is not a dosing recommendation as that must come from your medical care team. We'd also like to stress the importance of reviewing and discussing all infant acid reflux treatment intentions with your doctor and we encourage you to refer anybody in your care provider team to review this website and this page.
PPI stands for proton pump inhibitor. PPI's block the production of acid at the parietal cell where production occurs. PPI’s can only block the proton pumps that are active (producing acid). If the pumps aren’t producing acid then the PPI has no effect.
Some products that might sound familiar are Nexium, Prilosec, Prevacid, omeprazole and lanzoprasole. PPI’s such as omeprazole and lanzoprasole in OTC or Rx versions, can be used with TummyCare Max® under the guidance of your physician. More on PPI's here.
A Drug regimen is the drug that you take, how much you take per dose, and how often you take it. In addition the length of treatment is part of the regimen. For example, a common drug regimen for adult suffering from acid reflux disease could be Prevacid® (lansoprazole) 30mg twice per day. In this case the dose is 30mg and the dosage interval is twice per day.
Half life is the time required for the drug concentration in the bloodstream to drop by ½. In many it is used to determine the dosage interval (number of doses per day) and is measured in minutes or hours.
Volume of distribution relates to how the drug moves into the tissues of the body. It is sometimes used to determine the dosage.
Does that make sense so far?
Note that each of the listed PPI drugs below are currently approved by the FDA for pediatric use. That being said only Nexium is FDA approved in infants (for erosive esophagitis).
PPI drugs have an effect on the production of acid. That effect is related to the amount of drug that is absorbed into the body.
This amount of drug is measured as the AUC or Area Under the Curve. So, when your physician or medical care team are planning out a drug regimen with a PPI drug, the best thing to do is to try to achieve an AUC that is known to be enough of a dose to inhibit acid in twenty four hour and reduce damage and symptoms.
In other words, you have to give enough quantity of the PPI drug and frequently enough to get the desired effect.
Based on the MarciKids study when the dosing regimen of the PPI drug is insufficient your baby could continue to suffer from the symptoms of acid reflux disease. This could potentially be the cause of what is referred to by some moms as the acid battle.
PPI's are very specific in where they work in the body and are only active in a very specific place, the acid secreting portion of a cell called the parietal cell. Since PPI drugs only work on the acid secreting cell they have generally a good safety profile. PPI drugs are known as prodrugs because they are not active in the bloodstream. PPI's only become active when they pass into the acid secreting portion of the parietal cell (the cells in the stomach that make acid). It’s important to discuss this with your physician and medical care team.
This PPI dosing information page, the dosing chart and the dosing calculator below can be used by your medical care team, if they are interested in using MarciKids dosing, to assist in figuring out the optimal dose for your baby based on the age and weight of your child.
Your medical team will also discuss with you an important part of the treatment regimen which is the weaning or discontinuing PPI drugs all together.
There s some controversy to whether the half life of a PPI changes with in younger verses older children and adults. The graph below shows the half life of lansoprazole compared to age in infants and children. As you can see there is a relationship between age and half life with some degree of variability. This is important to consider because half life effects the AUC and as mentioned AUC has been correlated with acid inhibition in PPI medicines.
Tran A, Rey E, Pons G, Pariente-Khayat A, d'Athis P, Sallerin V, Dupont C. Pharmacokinetic-pharmacodynamic study of oral lansoprazole in children. Clinical Pharmacology and Therapeutics. 2002;71: 359-367.
If an adult with GERD takes 1-2 dose per day, such as lansoprazole, to achieve symptoms of acid reflux control, it is plausable that an infant could need 2-3 doses per day.
The MarciKids study showed that infants responded best to 2-3 doses a day. This may be a reflection of the shorter half-life when compared to adults.
It has been shown that infants have a larger Volume of distribution for PPI’s than adults.
In general the volume of distribution is often related to the dose needed.
The dose directly effects the area under AUC.
There is variation in the measurement of V.dist in infants and as such this is an approximation. Your medical care team may agree that some infants or children just require a higher dose to control acid reflux symptoms so there may be times when your medical care team would want to increase the milligram (mg) per milliliter (mL) concentration and/or the dose.
Based on this process indicated on this PPI dosing information page, the estimated half-life for this child would be 0.5 hours. Published data indicates that the normal adult has half-life of 1.5 hours for lansoprazole. By dividing the adult half-life of 1.5 hours by this child's half-life of 0.5 hours (as indicated on the table above), we know this child would eliminate the lansoprazole three times faster then the adult.
The average adult takes 1 dose per day (baseline from above) to achieve good acid control, so this one year old child would be expected to need 3 doses per day (3 x 1). So we know that this child will need 3 doses per day. The MarciKids study showed that infants responded best to 3 doses a day because they metabolize so quickly.
Now lets calculate the dose. The amount of PPI is determined by multiplying the volume of distribution and the child's weight. For lansoprazole and omeprazole, research has shown that the V.dist (volume of distribution) is 3 to 3.5 times larger in infants than in adults. The average adult dose is approximately 0.2 mg/pound, therefore,
3 x 0.2 mg/pound = 0.6 mg/pound per dose and
3.5 x 0.2 mg/pound = 0.7 mg/pound per dose
There is variation in the measurement of V.dist in most infants and as such this is an approximation. Some infants or children just require a higher dose to control acid reflux symptoms so there may be times when you would want to increase the milligram (mg) per milliliter (mL) concentration and/or the dose.
This information is provided for your medical care team if they decide to proceed with the MarciKids dosing.
Just enter the baby's weight in the appropriate age category. When entering the baby's age please use actual age and not adjusted age if the baby was born prematurely. Weight should be entered in pounds.
The charts below are ranges of doses according to MarcKids study and intended for use by your medical care team.
This information is provided for your medical care team if they decide to proceed with the MarciKids dosing. Just enter the baby's weight in the appropriate age category.
When entering the baby's age please use actual age and not adjusted age if the baby was born prematurely. Weight should be entered in pounds.
The charts below are ranges of doses according to MarciKids study and intended for use by your medical care team. Some infants needed higher than MarciKids dosing and some did well on lower doses.
These charts below are conclusions to effective dosing of PPI's in infants according to Marcikids and can be used as a reference as your medical team continues to use PPI's to treat your baby's reflux or GERD.
| Childs Age|| Doses per pound of body weight|| Doses per |
|Under 3 months old||0.7mg to 0.8mg of PPI per pound of body weight||3 times per day|
|3 to 6 months old||0.6mg to 0.7mg of PPI per pound of body weight||3 times per day|
|7 months to 2 years old||0.45mg to 0.6mg of PPI per pound of body weight||3 times per day|
|2 years old or older||0.45mg of PPI per pound of body weight||2 to3 times per day|
|5 years old or older||0.35mg to 0.45mg of PPI per pound of body weight||2 times per day|
| Childs Age||Doses per pound of body weight|| Doses per |
|Under 3 months old||0.7mg of PPI per pound of body weight||3 times per day|
|3 to 6 months old||0.6mg of PPI per pound of body weight||3 times per day|
|7 months to 2 years old ||0.45mg of PPI per pound of body weight||3 times per day|
|2 years old or older||0.45mg of PPI per pound of body weight||2 to 3 times per day|
|5 years old or older||0.35mg of PPI per pound of body weight||2 times per day|
Your medical care team may want to start your infant with a lower dose and increase over time as needed. If your medical team decides to begin using a compounded suspension with or without TummyCare Max® but not seeing improved symptom control from acid reflux disease a higher dose might be prescribed by your physician. As your new prescription will outline this will be accomplished by giving your baby a little more of the PPI suspension at each dosing time. If your baby is experiencing excess gas your physician may find it helpful to have the suspension compounded at a higher mg per ml concentration.
As your physician may discuss with you it may take ten to fourteen days to see the results of a PPI treatment on the symptoms of infant GERD. Be patient, it can take time. This why your physician may want to stay at a specific dose for a period of time.
Some Moms have commented that symptoms can get a little worse before they get better. Parents have referred to this as the acid battle. The acid in the stomach is very high in concentration when starting a proton pump inhibitor medication and a drug regimen. This of course is what's causing the infant acid reflux symptoms. It also causes the biggest difficulty when beginning your infants drug regimen. This is called "The Acid Battle" and we get into great detail about this subject on "The Acid Battle" page.
Your doctor may want to wean or titrate your baby up or down from PPI’s and may find the information on the weaning page useful. This can assist in the process in making the dosing up process as smooth as possible. Please read about it here on the Weaning page.
If you have any additional questions, please feel free to contact our Our Support Team.