Selected pharmacologic options for a child with upper gastrointestinal bleeding

	Dose	Category
Acid suppression (IV)*
Esomeprazole	Intermittent dosing:	PPI
	Infants: 0.5 to 1 mg/kg/dose IV once daily
	Children 1 to 17 years:
	<55 kg: 10 mg IV once or twice daily
	≥55 kg: 20 mg IV once or twice daily
	Adults: 40 mg IV twice daily
	Continuous IV infusion:^[1]
	1 mg/kg IV bolus (maximum 80 mg), followed by infusion of 0.1 mg/kg/hour (maximum 8 mg/hour)^¶
Omeprazole (IV preparation not available in the United States)	Children and adolescents:^[2] 0.5 to 3 mg/kg IV daily in 1 or 2 divided doses (maximum 80 mg daily)	PPI
	Adults: 40 mg IV twice daily
Pantoprazole	Intermittent dosing:	PPI
	Children and adolescents:
	<40 kg: 0.5 to 1 mg/kg IV once or twice daily
	>40 kg: 20 to 40 mg IV once or twice daily
	Adults: 40 mg IV twice daily
	Continuous IV infusion:^[1]
	1 mg/kg IV bolus (maximum 80 mg), followed by an infusion of 0.1 mg/kg/hour (maximum 8 mg/hour)^¶
Acid suppression (oral)^Δ
Omeprazole	Children and adolescents: 1 to 3 mg/kg daily^[3] (maximum 80 mg daily) in 1 or 2 divided doses	PPI
	Adults: 40 mg twice daily initially, followed by 20 to 40 mg once daily (maintenance dose, once risk of recurrent bleeding is low)
Esomeprazole	Infants 1 month to 1 year (daily):	PPI
	3 to 5 kg: 2.5 mg
	5 to 7.5 kg: 5 mg
	7.5 to 12 kg: 10 mg
	Children 1 to 11 years (daily):
	Weight <20 kg: 10 mg
	Weight ≥20 kg: 10 mg or 20 mg^◊
	Children ≥12 years and adults: 40 mg twice daily initially, followed by 20 to 40 mg once daily (as a maintenance dose, once risk of recurrent bleeding is low)
Pantoprazole	Children 5 to 11 years:	PPI
	Weight 15 to 40 kg: 20 mg once daily
	Weight >40 kg: Use adult dose
	Children ≥12 years and adults: 40 mg twice daily initially, followed by 20 to 40 mg once daily (as a maintenance dose, once risk of recurrent bleeding is low)
Vasoactive agents
Octreotide	Children: 1 to 2 microgram/kg IV bolus (maximum 50 micrograms), followed by 1 to 2 microgram/kg/hour as a continuous IV infusion (maximum 50 micrograms per hour)^[4]; initial bolus may be repeated once in the first hour if needed	Somatostatin analog
	Adults: 50 microgram IV bolus followed by a continuous IV infusion of 50 micrograms per hour; initial bolus may be repeated once in first hour if needed

Pharmacologic options for a child with UGIB. Acid suppression is appropriate for most children with clinically significant UGIB. Children with signs of significant bleeding and active blood loss (eg, hypovolemia, cardiac instability) require immediate stabilization and should be transferred to a pediatric intensive care unit if possible. In general, initial pharmacologic treatment of serious UGIB includes the use of high-dose or continuous IV PPI therapy for acid suppression, which is continued during the period of highest risk for rebleeding (eg, first 3 days). Vasoactive agents may be helpful for selected cases of vascular bleeding (eg, from esophageal varices).

IV: intravenous; PPI: proton pump inhibitor; UGIB: upper gastrointestinal bleeding; H2RAs: histamine 2 receptor antagonists.
* IV famotidine (a H2RA) may be used instead of a PPI, but H2RAs are less effective than PPIs in controlling bleeding of peptic ulcers, based on data in adults. For additional information, refer to topic reviews on management of peptic ulcers.
¶ Continuous dosing of IV esomeprazole and pantoprazole is not well established; this protocol has been used and reported by some centers^[1].
Δ Optimally, orally administered PPIs are given once daily before the first meal of the day (or if given twice daily, prior to the first meal and the evening meal). Other oral PPIs may be used, including rabeprazole and lansoprazole. For dosing, refer to pediatric drug monographs or topic reviews on gastroesophageal reflux disease in children and adolescents.
◊ In general, the pediatric dose should not exceed the higher end of the adult dose range. On a milligram per kilogram basis, doses of some of the PPIs needed for children are greater than those for adolescents and adults, to obtain a similar degree of acid suppression.

References:

Neidich GA, Cole SR. Gastrointestinal bleeding. Pediatr Rev 2014; 35:243.
Owensby S, Taylor K, Wilkins T. Diagnosis and management of upper gastrointestinal bleeding in children. J Am Board Fam Med 2015; 28:134.
Hassall E, Israel D, Shepherd R, Radke M, Dalväg A, Sköld B, Junghard O, Lundborg P. Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group. The journal of pediatrics 2000;137(6):800-7
Eroglu Y, Emerick KM, Whitingon PF, et al. Octreotide Therapy for Control of Acute Gastrointestinal Bleeding in Children. J Pediatr Gastroenterol Nutr 2004; 38:41.

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Selected pharmacologic options for a child with upper gastrointestinal bleeding