Proton pump inhibitors in children: indications and safety

INTRODUCTION: Proton pump inhibitors (PPIs) are among the most frequently prescribed medications in pediatric practice. While highly effective in acid-mediated disorders, concerns regarding overuse, inappropriate indications, and potential adverse effects have emerged, particularly in infants and children with nonspecific symptoms. AREAS COVERED: This review summarizes the current evidence on the indications, efficacy, and safety of PPIs in the pediatric population. A literature search was performed in PubMed/MEDLINE and Embase, supplemented by landmark earlier studies and current clinical practice guidelines. We discuss guideline recommendations and examine the role of PPIs across different clinical scenarios including gastroesophageal reflux disease, esophagitis, eosinophilic esophagitis and special populations. Particular attention is given to emerging data on adverse outcomes, including infections, microbiome alterations, and long-term safety concerns. Strategies for appropriate prescribing, deprescribing, and individualized patient management are also addressed. EXPERT OPINION: PPIs remain overprescribed in pediatrics, often for indications lacking clear benefit. Future efforts should prioritize diagnostic precision, short-term therapeutic trials and systematic deprescribing strategies. A shift toward stewardship-based prescribing, combined with improved clinician education and use of objective diagnostic tools, is essential to optimize outcomes and minimize unnecessary exposure.