Major Gastrointestinal Bleeding and Stress Ulcer Prophylaxis for Pediatric Critical Asthma: A Multicenter, Retrospective Study

Background: For children hospitalized for critical asthma (CA) in the pediatric intensive care unit (PICU), a perception that systemic corticosteroids impairs epithelial cytoprotective mechanism and increases the risk of gastrointestinal (GI) bleeding has led to a common but unproven practice of administering stress ulcer prophylaxis (SUP) with histamine-2-antagonists or proton pump inhibitors (PPIs). We sought to estimate the rate and describe the trends of SUP prescribing by using a large, multicenter registry. In addition, we explored for differences in frequency of GI bleeding, gastritis, and SUP-related adverse events.

Methods: We performed a retrospective, multicenter cohort study using the Pediatric Hospital Information System registry among 42 children’s hospitals from 2010 through 2019. We included children 3-17 years of age admitted to the PICU for CA receiving corticosteroids. The primary outcome was chronologic and regional variation in SUP prescribing over the study period assessed by Joinpoint regression and Pearson’s correlation. We identified and compared rates of GI bleeding, gastritis, and enteric ulceration including surrogate markers such as billing data for packed red blood cell transfusion, octreotide infusion, and sucralfate. For those provided SUP, we estimated the rates of SUP-related adverse events including C. difficile colitis, necrotizing enterocolitis, and thrombocytopenia.

Results: A total of 30,177 children were included for study of which 10,387 (34.4%) received SUP. No episodes of GI bleeding, transfusion of packed red blood cells, or octreotide infusions were recorded. One subject receiving SUP developed gastric ulceration and 32 (0.1%) experienced gastritis. SUP prescribing rates varied widely by institution from 5.5% to 97.2% with no correlation to admission volumes (see Figure 1). A linear chronologic trend in SUP prescribing was observed with rates increasing from 25.5% in 2010 to 42.1% in 2019 (mean increase of 1.9% annually) (see Figure 2). We observed rare SUP-related adverse events with no episodes of C. difficile colitis or necrotizing enterocolitis.

Conclusion: Although children with CA frequently receive SUP, we observed no episodes of GI bleeding over a 10-year period. Rather than the ubiquitous prescribing of SUP on the basis of corticosteroid exposure alone, we advocate for a targeted approach that instead considers known risk factors for GI bleeding such as coagulopathy, invasive ventilation, or enteric tube placement.