Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns

Pharmacological therapy of gastroesophageal reflux in preterm infants

Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.

Neonatal apnea and gastroesophageal reflux (GER): is there a problem?

Apnea of prematurity and gastroesophageal reflux (GER) are both common occurrences in preterm infants and widely perceived to be causally related. We seek in this review to provide a potential guideline for neonatal GER non-pharmacologic and pharmacologic therapy. Available physiologic data suggest that when there is a temporal relationship apnea may be more likely to predispose to GER via esophageal sphincter relaxation than vice versa. Measurement of multiple intraluminal impedance via esophageal catheter in addition to esophageal pH has enhanced our understanding of GER, although it also did not demonstrate a causal relationship between apnea and GER. The incidence of GER may be modified by thickening feeds and position change without adverse effects. In contrast, pharmacotherapy including acid suppression therapy may have adverse effects and should only be used in infants with clear evidence of clinical benefit.

Prevention of necrotizing enterocolitis in preterm very low birth weight infants: is it feasible?

Necrotizing enterocolitis (NEC) is still one of the most catastrophic intestinal emergencies in preterm very low-birth weight infants. Primary prevention of NEC should be the priority, since NEC frequently progresses from nonspecific signs, to extensive necrosis within a matter of hours with medical or surgical treatment, making successful treatment and secondary prevention difficult to achieve. Currently available strategies for primary prevention of NEC include antenatal glucocorticosteroids, breast milk feeding, cautious feeding strategy, fluid restriction and probiotics. Nonetheless, based on current research evidence, mixed flora probiotics, and/or breast milk feeding, would appear to be the most effective feasible methods in the prevention of NEC at present.

Protracted maturation of pancreatic-specific elastase 1 excretion in preterm infants of extremely low gestational age

OBJECTIVES

The aim of the present study was to better understand the exocrine pancreatic function of extremely preterm infants.

METHODS

Pancreatic-specific elastase 1 (PSE1) activity was determined in spot stool samples of 69 preterm infants of gestational age <32 weeks and birth weight <1250 g. Assays were conducted on samples collected at 2 (N = 56), 4 (N = 46), and 6 weeks of age (N = 23).

RESULTS

PSE1 activity increased from week 2 (median [interquartile range] 84 [48-187] μg/g) to week 4 (164 [87-251 μg/g; P < 0.001) but not thereafter (169 [82-298] μg/g at week 6). The maturational increase in PSE1 activity was observed only in infants of gestational age <28 weeks (P < 0.001). At 2 weeks after birth, PSE1 levels were lower in infants of gestational age <28 weeks than in infants of gestational age ≥ 28 weeks (77 [43-110] vs 165 [56-300] μg/g; P = 0.019), but this difference was less pronounced at 4 weeks (153 [77-226] vs 230 [108-503] μg/g; P = 0.070) and had disappeared by 6 weeks (163 [76-258] vs 175 [85-418] μg/g; P = 0.576). In infants on full enteral feeding regimens 4 weeks after birth, PSE1 levels were associated with weight gain per unit of energy intake (Rs = 0.431; P = 0.005). This measure of weight gain was lower (P = 0.040) in infants with PSE1 levels <200 μg/g (0.110 [0.081-0.139] g/kcal, N = 25) than in those with PSE1 levels ≥ 200 μg/g (0.139 [0.117-0.157] g/kcal, N = 15). Administration of pancreatic enzymes to infants showing PSE1 excretion levels <200 μg/g did not enhance weight gain.

CONCLUSIONS

: Extremely preterm infants have limited exocrine pancreatic function during the first weeks of life, which may contribute to growth failure.

Histamine-2 receptor blockers alter the fecal microbiota in premature infants

OBJECTIVES

Bacterial colonization is considered a major risk factor for necrotizing enterocolitis (NEC). The objective of the present study was to test the hypothesis that histamine-2 receptor (H2-) blockers alter colonic bacterial colonization by analyzing and comparing the fecal microbiota in premature infants with and without H2-blocker therapy using sensitive molecular biological techniques.

METHODS

Seventy-six premature infants ≤1500 g or <34 weeks gestation were enrolled in this case-controlled, cross-sectional study. Stool samples were collected from 25 infants receiving H2-blockers and 51 babies who had never received them. Following DNA extraction and PCR amplification of 16S rRNA, 454 pyrosequencing was undertaken and the resulting sequences were subjected to comparison with published sequence libraries.

RESULTS

Proteobacteria and Firmicutes were the major phyla contributing to fecal microbial communities. Microbial diversity was lower, relative abundance of Proteobacteria (primarily of the family Enterobacteriaceae) was increased, whereas that of Firmicutes was decreased in the stools of infants receiving H2-blockers compared with those who had never received them.

CONCLUSIONS

Although not designed to look specifically at the effect of H2-blockers on the incidence of NEC, our study suggests that their use lowers fecal microbial diversity and shifts the microfloral pattern toward Proteobacteria. These alterations in fecal microbiota may predispose the vulnerable immature gut to necrotizing enterocolitis and suggest prudence in the use of H2-blockers in the premature infant.

Role of pneumography and esophageal pH monitoring in the evaluation of infants with apparent life-threatening event: a prospective observational study

OBJECTIVE

To determine if a positive result on pneumography, diagnosis of gastroesophageal reflux disease (GERD), or nontreatment of those diagnosed with GERD with antireflux medications predicts an increased recurrence risk of apparent life-threatening event (ALTE) over the first 4 weeks of follow-up.

METHODS

Secondary analysis of a prospective, observational study of 300 infants diagnosed with ALTE.

RESULTS

The relative risk of recurrent ALTE was 1.26 (95% confidence interval = 0.47-3.38) among infants with an abnormal versus normal result on pneumography, 1.98 (1.02-3.86) among those diagnosed with GERD versus those not, and 0.46 (0.20-1.03) among those with GERD and started on antireflux medications versus those not started on such medications.

CONCLUSIONS

Positive pneumography for apnea or reflux does not predict an increase in recurrence rate of an ALTE. Infants diagnosed with GERD are more likely to have recurrent ALTE; treatment with antireflux medications may reduce this risk.

Prognostic values of multichannel intraluminal impedance and pH monitoring in newborns with symptoms of gastroesophageal reflux disease

OBJECTIVE

To evaluate the relationship between multichannel intraluminal impedance and pH monitoring (MII/pH) values in newborns with symptoms of gastroesophageal reflux disease (GERD) and clinical history in their first 3 years of life.

STUDY DESIGN

Sixty-four newborns with GERD symptoms who underwent MII/pH in the first weeks of life were enrolled into a clinical follow-up program. Follow-up visits were programmed at 1, 3, 6, 9, 12, 18, 24, and 36 months. Patients were divided into 3 groups according to duration of symptoms: short (1-3 months), medium (4-9 months), and long (>9 months), and MII/pH values in these groups were compared.

RESULTS

Fifty-three patients completed the 3-year follow-up. The number of patients with GERD symptoms decreased each month. A comparison of MII/pH values of the 3 lifetime symptom groups revealed differences in the impedance bolus exposure index (F = 83; P = .012) and proximal reflux frequency (F = 410; P = .022). These 2 MII variables showed an increasing trend from the short lifetime symptom group to the long lifetime symptom group. Weakly acidic reflux events, but not acidic events, were responsible for these differences.

CONCLUSION

MII/pH in newborns has prognostic value regarding the duration of GERD symptoms and provides useful information that clinicians may give parents about the prognosis of symptomatic infants. Impedance bolus exposure index and proximal reflux frequency seem to be the variables with the highest predictive value. Weakly acidic reflux events play an important role in determining the duration of GERD symptoms in newborns.

A critical comparison between the World Health Organization list of essential medicines for children and the Brazilian list of essential medicines (Rename)

OBJECTIVE

To perform a critical comparison between the Brazilian national essential medicines list (Rename, 2012) with the list of essential medicines for children (LEMC, 2011) of the World Health Organization (WHO), regarding the differences among drugs and formulations listed for children.

METHODS

The LEMC drugs were classified into four categories: 1) absent in Rename; 2) included in Rename but without any formulation suitable for children; 3) listed in Rename only in some formulations; 4) present in Rename in all formulations. The missing formulations were analyzed by therapeutic group. Alternatives present in Rename were searched.

RESULTS

From the 261 drugs of interest on the LEMC, 30.3% are absent from Rename, 11.1% are in Rename but without any pediatric formulation, and 32.2% are present in some but not all formulations listed in LEMC. Considering all formulations items listed in the LEMC (n = 577), 349 are missing from Rename, of these 19.6% due to their strength, and 18.5% due to the the dosage form. Useful formulations specific for neonatal care, respiratory tract, central nervous system, and anti-infectives, among other groups, are missing.

CONCLUSION

The lack of age-appropriate formulations of essential medicines for children in Brazil includes important therapeutic groups and indispensable drugs for severe clinical conditions. Some of these products exist in the Brazilian pharmaceutical market, but not in public facilities; others could be produced by national laboratories with commercial interest or stimulated by a specific governmental policy, as in other countries.

Inhibitors of gastric acid secretion drugs increase neonatal morbidity and mortality

AIMS

To analyze all evidence on the possible increase in morbidity and mortality determined by the use of inhibitors of gastric acid secretion (IGAS) drugs.

MATERIALS AND METHODS

We review all evidence exploring the adverse events associated with IGAS use in neonates.

RESULTS

Despite being prescribed in an off-label manner because of the perceived safety and potential benefit demonstrated for older populations, IGAS are being increasingly used in the neonatal period with much evidence derived from adults and children. Few data are available for neonates and indicate an association between IGAS use with infections and necrotizing enterocolitis (NEC), and with an increased mortality. Delayed gastric emptying, increased gastric mucus viscosity, modification in microbiota, and impairment of neutrophils functions are possible mechanisms of adverse events associated with IGAS use.

CONCLUSIONS

A careful prescription of IGAS is crucial in order to reduce iatrogenic damage in neonates.

Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease?

BACKGROUND

It has become common practice to empirically treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications. However, evidence to support the effectiveness of these medications in the pediatric population is limited. With multiple studies in adult patients indicating increased risk of infection, we reviewed the literature to determine the association between acid-suppressive medications and serious adverse effects in infants and children.

METHODS

We conducted a PubMed search on the adverse effects of H2 antagonists and proton pump inhibitors in pediatric patients. The studies selected were original research and systematic reviews with control groups and study objectives evaluating the relationship between acid-suppressive medications and serious adverse effects (namely, infections).

RESULTS

Fourteen studies met our inclusion criteria. The majority of studies found a significant association between acid-suppressive medications and the risk of necrotizing enterocolitis, sepsis/bacteremia, pneumonia, and gastrointestinal infections in infants and children.

CONCLUSIONS

Given the questionable efficacy of H2 antagonists and proton pump inhibitors and the growing evidence of increased risk of serious infections, acid-suppressive medications should be used cautiously in infants and children suspected of having gastroesophageal reflux disease.