Exercise caution with PPIs or H2RAs use in neonates with upper GI bleeding

Delhi: The risk of gastrointestinal (GI) bleeding, a common occurrence in sick newborns admitted to neonatal intensive care, can be reduced by the use of histamine-2 receptor antagonists (H2RAs), according to a recent Cochrane review. But there is low-quality evidence that use of an inhibitor of gastric acid (H2RA or proton pump inhibitor) reduces the duration of upper gastrointestinal bleeding and the incidence of continued gastric bleeding. And, there is no evidence that the use of an inhibitor of gastric acid in newborn infants affects mortality or the need for blood transfusion.

Findings of the study suggest that need for caution while using PPIs or H2RAs in neonates with gastrointestinal bleeding.

Upper gastrointestinal bleeding is common among sick newborns admitted to intensive care. It may be associated with allergy to milk proteins or reflux of milk (gastroesophageal reflux). Symptoms include vomiting of material which can be either bloodstained or like coffee grounds in appearance; and black, tarry stools. It is typically a self-limiting and mild condition Bu can be severe when associated with other underlying conditions.

Daniel Stephen Green, Australian National University, Acton, Canberra, Australia, and colleagues assessed how different medications for gastric acid inhibition (PPIs, H2RAs, antacids) or stomach lining protection (sucralfate or bismuth salts) helps in the prevention or treatment of upper gastrointestinal bleeding in preterm and term infants.

The researchers searched the online databases for randomised trials involving preterm and term neonates. Trials were included if they used a proton pump inhibitor, H2 receptor antagonist, antacid, sucralfate or bismuth either for the prevention or treatment of upper gastrointestinal bleeding.

Eleven studies with 818 infants met the criteria for inclusion in this review.

Key findings of the study include:

• Four trials included 329 infants in neonatal intensive care units and used a histamine 2 receptor antagonist for prevention of upper gastrointestinal bleeding. These four trials demonstrated a reduction in the incidence of upper gastrointestinal bleeding with a histamine 2 receptor antagonist, but no change in mortality.


• Outcomes such as serious gastrointestinal problems (e.g. necrotising enterocolitis) and infections were not reported.


• Seven trials with 489 infants enrolled sick newborn infants with upper gastrointestinal bleeding and used either a histamine 2 receptor antagonist or a proton pump inhibitor for treatment.


• Use of a histamine 2 receptor antagonist or proton pump inhibitor in a treatment context was associated with a reduction of both duration of upper gastrointestinal bleeding and continued upper gastrointestinal bleeding; however, it did not affect mortality or requirement for blood transfusion. No long‐term follow‐up was reported.


• There were no significant subgroup differences in duration of upper gastrointestinal bleeding or of continued upper gastrointestinal bleeding according to the type of inhibitor of gastric acid.


• A single trial (38 infants) reported no difference in anaemia requiring blood transfusion from use of an H2 receptor antagonist compared to no treatment.

"Although there is moderate‐quality evidence that use of an inhibitor of gastric acid reduces the incidence and duration of upper gastrointestinal bleeding in newborn infants, there is insufficient safety data in this population. The implication of this is that caution should be applied when deciding whether to use an inhibitor of gastric acid in sick newborn infants until additional studies are performed," write the authors.

To read the complete study log on to https://doi.org/10.1002/14651858.CD011785.pub2