Clicking here will take you to the “Selecting Treatment” page. This is where you learned about Diet (Breastfeeding and Formula Feeding) and Medicines.
So now you know a bit about the different medications used to treat acid reflux/GERD (from the Medicines page, link provided above). And, you’ve addressed possible dietary issues (protein intolerances, allergies). Now it’s time to learn about the dosing of these medications, so that you can discuss your baby’s situation with your doctor. And, it’s time to learn how to give, or administer, these medications to an infant. Many pediatricians are not comfortable with prescribing high doses of medication to infants. Since you’re here, and you’re learning a lot, it may just be time to get to a Pediatric Gastroenterologist, a ped GI. It can be difficult to get an appointment, so, at this point, make the appointment; you can always cancel it if your baby improves by the time the appointment comes up. Use the Directory, in the Menu! And, be sure to pay if forward! Contact Us with your reviews of all types of medical professionals!
Always check with your doctor and pharmacist!
I will post here the dosing for some PPIs, but make sure to always verify! Your pharmacist has a handy device called the ipharmacist. This is where they look up dosing. Dosing might change, so it’s a good idea to double-check! With H2 Blockers (dosing info for H2 Blockers), babies tend to ‘plateau.’ If the medicine was working and it seems to stop working, check the dose and see if it can be increased. These medicines are prescribed by your baby’s weight (and age), so if your baby has gained any weight since first being prescribed her current dose, it most likely can be increased. If your baby has gained weight and the dose is still effective, great! This is a good sign! If your baby is at the highest dose for his/her weight, s/he may have developed a tolerance to it and it no longer is as effective as it once was. Always question! I once went to the pediatrician and spouted off my knowledge of Zantac dosing (I was there for my non-refluxer’s ear infection) and she told me I was wrong! She whipped out her Physician’s Reference and showed me lower dosing than what I was telling people! It turns out, I was not wrong; pediatricians (can) go by their dosing and there very well may be another dose recommended for more severe cases. Check!
[WEIGHT-WEAN: when you look at the dosing chart, keep in mind you do not HAVE to increase baby’s dose with weight gain. If pain is an issue, and baby is due for an increase in her/his dose, then follow the dosing chart. From Lindsay Robinson Ames: “I was a Zegerid (rx) user with my baby and I will share our personal experience: I had to adjust her dosage, increase it, to get her reflux controlled. However, I didn’t need to increase her dose with weight gain, once her acid reflux was controlled. It’s considered a ‘weight wean.” Definitely increase the dose if your baby is still struggling with the reflux pain, but don’t feel you absolutely have to increase, just because baby had gained weight and “outgrown” the current dose. The longer you can go without increasing the dose the better the indicator that the reflux is being outgrown.]
Once you know the dose, then you need to figure out the FORM of PPI (how will you administer it?).
Immediate Release (IR) & Delayed Release (DR): Which one should you choose?
- With Immediate Release the administration of the medication is not dependent upon whether or not your baby has an empty stomach;
- With Immediate Release you may administer the medication at any time.
- With Immediate Release you do not have to worry about medicine being effective during the night; it IS effective at night.
- With Immediate Release you have to check to make sure that it really IS Immediate Release! Read below!
- With Delayed Release, you must administer on an empty stomach, followed by a ‘meal’ thirty (30) minutes later.*
- With Delayed Release the presence of food can significantly lower the absorption of the drug.
- With Delayed Release when using beads from a capsule, it is most effective to administer them with something acidic, such as a small amount of apple sauce or juice, pear purée or juice, or pedialyte.
- With Delayed Release the acidic ‘something’ that is needed is to help keep the pH of the stomach contents low enough to keep the coating of the beads in place. If the coating dissolves while the drug is still in the stomach, it is then vulnerable to exposure to pockets of acid and degradation. The coating is specifically designed not to come off until it reaches the higher pH environment of the duodenum (the first section of the small intestine). Here the drug is absorbed into the blood stream.
- With Delayed Release you must keep in mind that the medicine may not be as effective during the night. You will find more about this, below, see: Night Acid and Delayed Release vs. Immediate Release PPIs.
Immediate Release (administer at any time & not issue with night acid):
- Properly made compound is prescribed by doctor; finding a pharmacy to do this is near impossible (you are better off looking at number 4 and 5 in this list). You may attempt to try to tell doctor/pharmacist how compound is to be made.
- Zegerid 40mgs packets are prescribed by doctor (there is still ‘more’ that must be addressed regarding this; you must add more buffer). How to Mix Zegerid Rx 40mgs packets
- Zegerid 20mgs packets are prescribed by doctor. The 40mg packets are preferable, however, if you must: How to Mix Zegerid Rx 20mg packets…
- A liquid is made from using OTC Zegerid, OTC Omeprazole and other OTC ingredients: Home Compounding Recipes Mixing OTC Zegerid and Rx Packets.
- First brand Kit is prescribed by doctor for pharmacist to use to make compound using either omeprazole or lansoprazole. This is a wonderful option IF it can be prescribed to be refilled every ten (10) days. This can be difficult, as most pharmacists believe that the First brand kits are stable for thirty (30) days and this just is not so (the company that produces the First brand kits states this). Here is a study to show that it the compounded PPI is stable for +/- 10 days: Stability of Extemporaneously Prepared Lansoprazole Suspension at Two Temperatures. Click here the link –> to find how Some do actually get the First Kits prescribed ‘properly.’
- Find pharmacist/pharmacy that will use sodium bicarbonate vials and PPI capsules (instead of them compounding it for you or using the First kit). Pharmacist can send you home with three (3) big vials (50 ml each) of sodium bicarbonate and the PPI capsules. You then open up the capsules and pour the beads into the sodium bicarbonate every ten (10) days. You do not need a separate prescription for the sodium bicarbonate. You can also flavor each dose separately, as needed. Try a local compounding pharmacy.
Delayed Release (administer on an empty stomach, followed by a ‘meal’ 30 minutes later* & take Night Acid into consideration):
- OTC capsules (not zegerid) are purchased and the beads from the capsules are administered. Beads are administered with a small amount of something acidic (ex: small amount of apple sauce or juice, pear puree or juice, or pedialyte). There is Youtube video, at the very bottom of this page, showing (one way of) how to do administer the beads from a PPI capsule. You can also use your finger with the beads, dip/roll in purée and wash down with water in a syringe. Or, you can use a babyhood spoon with the purée, sprinkle the beads on top and wash down with water.
- Prevacid Solutabs are prescribed by doctor; dose is mixed with enough water to administer comfortably. Some simply hold the piece of the solutab in the inside of the baby’s cheek until it dissolves.
- Nexium packets are prescribed by doctor. Dose is mixed with enough water to administer comfortably.
There is a YouTube Video, at the bottom of this page, showing how to use apple juice and PPI capsule beads
* It is more important to get the pumps on at the time the PPI gets into the bloodstream – hence the 1/2 to 1 hr prior to feeding (or eating) – the empty stomach aspect is more important than the aspect of waiting 30 mins then having a meal. (waiting the 30 minutes is ideal and some say it is better to wait 45 minutes with nexium)
Empty Stomach: Usually 2-3 hours after a meal, unless Delayed Gastric Emptying (DGE) has been diagnosed. A full meal: 4-5 oz of formula.
30 Minute Rule: Proton Pump Inhibitors need to get to the pumps, so they are given an enteric coating (ex: the beads in the capsules) that will only be dissolved in a high pH environment. This coating protects the drug from the acid while it is in the stomach, until it can pass into the first section of the small intestine, known as the duodenum. In the more alkaline environment of the duodenum, the enteric coating is dissolved and the drug is absorbed into the blood stream and is carried to the proton pumps in the stomach lining, where it begins to block the proton pumps. The whole process takes 30 minutes.
Night Acid and Delayed Release vs. Immediate Release PPIs: See below.
What’s all this about Zegerid?
See above, “Immediate Release,” numbers 2, 3, & 4.
Zegerid has the drug Prilosec in it and it has buffers, so that it can be given with food. Why should you care about Zegerid? Because you can give the medicine at any time, even with food, and you don’t have to worry about timing it around an empty stomach. Links above. You also do not have to worry about Night Acid. See below.
Night Acid and Delayed Release vs. Immediate Release PPIs
Something else to consider is what’s referred to as an ‘acid dump.’ The following was posted by Rachel T., from Facebook:
SoluTabs and any of the delayed release PPIs do not work at nighttime very well. Let me [PharmD Researcher] clarify, from 9 pm till about 2 am there is very little acid production (this is because of ancient genetic encoding; ancient people ate their evening meal while it was day light, at about 6pm or so, then they’d go to sleep and their bodies’ acid would ‘kicks-in’ in the early am (~2 am to 6 am), to kill any bacteria that were ingested). This remnant genetic predisposition is still with us. What do PPIs require to work??? (Answer: actively secreting acid pumps). How long is the PPI in your baby’s system? (for approx 120 minutes after you give it). If the acid pumps (proton pumps) are not on during that time period then acid will not be blocked. Immediate release PPIs (such as Zegerid) have a buffer in them and that turns on the acid pumps (in addition to protecting the PPI from acid degradation). So Immediate acting PPIs can be given without regard to meals (or even in the bottle).
Delayed release PPI such as Prevacid OTC need to have active acid secreting cells (“pumping”) in order to block the pumps. The body shuts down pumps after 7 pm to ~3am. If you give the delayed release Prevacid, then it will be in the baby’s body for 3.5 to 4 hrs after administration, then it will be gone. SO, if you give the PPI after 5:30 it will have no effect because no pumps will be on while the Prevacid is in the bloodstream. It is simple really, PPI drugs (such as SoluTab) can only block pumps that are in place and ready to make acid.
Well it is really quite interesting. The acid pumps are finite (meaning there are only so many available in a 24 hr period). When you use a buffer and immediate release PPI – the buffer hits the stomach and raises the pH. This makes the stomach lining send a signal to the acid secreting cells (parietal cells) to wake the pumps and get some of them making acid just a the PPI part hit the pumps and shuts them down. When you use a buffer, a lot of these pumps get used up. Therefore, by giving a dose around 8 or 9pm, or thereabouts, the pumps are exhausted and there aren’t any to come on in the 2am period – so then there is no acid dump.
the SoluTab contains Prevacid in enteric-coated granules (inside the SoluTab). The medicine (lansoprazole) is absorbed in 1.5 hrs and the amt of time it is in the system is 120 minutes. So approx 3.5 hrs after a dose there is no drug in the system to block the acid pumps (called proton pumps). The nighttime acid begins at 2am and continues till 7 am (roughly). So, if you give a dose at 5:30pm then it is gone at 9pm (way before the acid pumps start making the nighttime acid).
Immediate Release PPIs (such as Zegerid) has a buffer that stimulates those pumps to come on (that would have come on from 2 am till ~7am) and then blocks them while they are on.
You have a period of acid dump from 2 am till about 7am. That is the period of maximal acid dump at night. So, if the drug is in the bloodstream for a maximum of ~2hrs (remember the absorption occurs after ~1.5hrs so, from the 1.5hr mark forward for ~2 hrs you have coverage for any acid being made. So let’s say you time it perfectly and give the dose at 1/2 hr after midnight so that the drug would be in the blood stream at 2 am (it takes 1.5 hrs to get absorbed) Then at 2 am you would have drug present for 2 hrs – till 4am. Then no drug – but body still making loads of acid (nocturnal acid). From 4 am on there would be no protection from acid.
The acid pumps (called proton pumps) are in the acid making cells (called parietal cells). They make acid when signaled to do so. They are signaled to make acid after you begin eating (mainly by food or milk which raises the pH in the stomach). After your evening meal they go dormant till approx 2am, then they come on and make a large amt of acid. This is because long ago we did not cook things well (no stoves existed, hardly any fire existed) and the large meal of the day was at night then you went to sleep. During the night your body would make a lot of acid to kill the bacteria you ingested (that is how you lived through the night-in essence). So we still have that 2 am to 7 am acid dump.
The other thing you have to know is a little PPI pharmacology – PPIs can only turn off acid pumps that are already on. So if the pumps are not on (in the resting phase) and you take a PPI (that does not have a buffer) then the PPI will get absorbed and when the PPI gets to the parietal cell it will find no acid pumps that are on and it will not be able to shut off any pumps and the PPI will be removed from the body (just as all drugs are removed from the body) through metabolism and elimination. If you take the PPI in an immediate release form with a buffer, then the buffer will turn on a large quantity of acid pumps and they will all get shut off by the PPI. Then later in the early morning hours when the body tries to make the nighttime acid dump (there will be no acid pumps remaining) – so no acid dump. The studies were performed (not by me) but over hundred’s of studies who look at the baseline pH (before treatment) and then after treatment. So all this baseline data exists and in the observation of these baseline data. And it was observed (quite obvious) that there was all this nighttime acid.”
Quoting Doreen: “If they do not eat at night there is nothing to turn the pumps on to get the medication going. If they eat at night then the pump, acids and meds can do their little dance.”
OTC Prevacid and Apple Juice – How To
Simple and quick. I usually encourage people to do a test run using water (without the beads) to get familiar with how much to push the syringe in. There’s a little “pop” on the Tylenol syringes that can send meds shooting out if you’re not used to working with them and don’t cover the end.
NOTE: The information on this page is not exhaustive and complete accuracy is not guaranteed. Please consult your doctor with any questions you may have regarding the treatment of your child.