Stress ulcer prophylaxis in critically ill children: A systematic review
Duffett M, Choong K, Foster J, Gilfoyle E, Lacroix J, Cook DJ.
Aims & Objectives
Critically ill children are at increased risk of gastrointestinal bleeding and the majority receive prophylaxis. Despite common use, it is not clear if the benefits of prophylaxis outweigh the risks. Our objective was to assess the effect of stress ulcer prophylaxis in critically ill children on the outcomes of clinically important bleeding, ventilator associated pneumonia (VAP) and C. difficile infection.
We searched PICUtrials.net (a comprehensive repository of published randomized controlled trials (RCTs) in pediatric critical care identified by searching MEDLINE, EMBASE, LILACS, and CENTRAL using comprehensive search strategies, updated Oct 8, 2015). We included RCTs comparing any pharmacological prophylaxis with placebo or no intervention. Pairs of reviewers screened studies for eligibility and abstracted data independently. We used the Cochrane Risk of Bias Tool to classify the trials’ risk of bias.
Four trials randomizing 465 children compared any pharmacological prophylaxis (proton pump inhibitors, histamine-2 receptor antagonists, antacids or sulcralfate) to placebo or no intervention were published between 1986 and 2002. Two (50.0%) were at high risk of bias due to lack of clinician blinding and incomplete data. The 3 trials randomizing 340 children that reported macroscopic or important bleeding did not find a difference between prophylaxis with any agent and no prophylaxis (RR 0.71; 95% CI 0.42 to 1.19, p=0.19). The single trial reporting VAP found no difference between prophylaxis with a PPI or H2RA and no prophylaxis (RR =1.14 ; 95% CI 0.74 to 1.77, p=0.54). No RCTs reported the incidence of C. difficile infection.
Any estimate of the effect of stress ulcer prophylaxis in critically ill children is very uncertain. The published RCTs are not sufficient to assess the balance of risks and benefits. A large RCT focusing on outcomes important to clinicians and families is needed.