Published online February 1, 2006
PEDIATRICS Vol. 117 No. 2 February 2006, pp. 531-532 (doi:10.1542/peds.2005-2230)
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COMMENTARY

Association of H2-Blocker Therapy and Higher Incidence of Necrotizing Enterocolitis: A Case of Excessive Collateral Damage?

Sanjay Patole, MD, DCH, FRACP

Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, University of Western Australia, Perth, Western Australia

Abbreviations: NEC, necrotizing enterocolitis

In this issue of Pediatrics Electronic Edition, Guillet et al1 report the association of H2-blocker therapy with higher incidence of stage II or greater necrotizing enterocolitis (NEC) in very low birth weight neonates using a case-control design. The finding is not necessarily surprising given the link between sepsis and NEC in preterm neonates2–4 and the association of antacid therapy with nosocomial infections that has been well known for at least 15 to 20 years in adult intensive care literature.5–12 Ironically, as the authors point out, as far back as in 1990 Carrion and Egan13 had reported that acidifying the feeds to a pH level low enough to inhibit bacterial proliferation in the stomach significantly lowered the risk (1 of 34 vs 8 of 34; P = .02) of NEC in preterm neonates. The median gastric pH level of the HCl-supplemented group was lower (3.0) than that of the control group (4.0) throughout the study (P < .001).13

The frequency of prophylactic H2-blocker therapy of up to 72.2% is disturbing given that there is not much high-quality evidence to support it.14–18 Clinically significant bleeding as well as the mortality related to stress-related upper-gastrointestinal ulcerations are currently an uncommon phenomenon, possibly because of the improved management of hypoxia and shock, with its accompanying gastric hypoperfusion in critically ill neonates.5,19–22 The fact that gastric acid alone is not the only culprit in the causation of stress ulcers was demonstrated clearly years ago by their occurrence in patients with congenital achlorhydria.23 Stress-ulcer prophylaxis has not been shown to significantly reduce the mortality rates in adult ICUs.24,25 It is also important to note that treatment with antacids or H2 blockers has been associated with significantly higher mortality rates in long-term ventilated patients compared with those treated with sucralfate.26

The study by Guillet et al has the strength of numbers, which are certainly needed for an uncommon and poorly understood illness such as NEC; however, a few drawbacks are worth mentioning.1 The single-most important risk factor for NEC is prematurity. It would have been helpful to analyze the data by controlling for at least gestational age rather than birth weight and for other confounding factors such as antenatal glucocorticoids, intrauterine growth retardation, enteral feeding, and Clinical Risk Index for Babies scores. Despite these issues, the findings by Guillet et al should serve as a reminder that everything, including gastric acid, is there for a purpose.10,27,28


   FOOTNOTES
 
Accepted Sep 8, 2005.

Address correspondence to Sanjay Patole, MD, DCH, FRACP, Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, University of Western Australia, Perth 6008, Western Australia. E-mail: sanjay.patole{at}health.wa.gov.au

The author has indicated he has no financial relationships relevant to this article to disclose.


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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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This Article
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