Treating pediatric patients with acid suppression drugs may cause changes in the microflora, which may predispose them to clinical infections, according to a study published in JAMA Pediatrics.
Acid suppression therapy is commonly used in infants and children and growing data suggests that use of these drugs is associated with an increased risk of upper respiratory tract infections and pneumonias. Yet, despite this possibility, these medications are often used to treat extraesophageal reflux symptoms such as cough and wheezing.
“We know that acid suppression use in children is increasing for treatment of atypical symptoms despite a lack data to support use,” according to lead study author Rachel Rosen, MD, of Boston Children's Hospital and Harvard.
“Furthermore, these medications have been associated with increased infection risk including pneumonia and upper respiratory tract infections but the mechanism behind these increased risks is not known,” Dr Rosen said. “We hypothesized that children taking acid suppression would have overgrowth of bacteria in the gastric fluid and, if this bacterial laden gastric fluid was refluxed and aspirated, changes in lung microflora would ensue.”
Dr Rosen and colleagues prospectively recruited 101 children between aged 1 and 18 years with chronic cough who were undergoing simultaneous upper gastrointestinal endoscopy and bronchoscopy for evaluation of respiratory symptoms. The researchers then collected gastric and bronchoalveolar lavage fluid from patients who were and were not taking acid suppression and did sophisticated cultures to determine the prevalence and concentration of bacteria from these 2 sites in these 2 pediatric populations.
“The goal of our study was to determine if children with respiratory symptoms who take acid suppression medications [H2 blockers and proton pump inhibitors] are at increased risk for bacterial growth in the stomach and the lungs,” she explained. “Prior studies addressing this have focused on critically ill intensive care unit patients who are on multiple medications and have indwelling tubes all of which could impact bacterial growth. This is the first study to determine the effects of these medications in ambulatory children using sophisticated culture methods.”
The researchers found that 46% of children taking acid suppression had bacterial growth from stomach fluid compared to 18% of untreated children. They also found that the median concentrations of bacteria in the stomach were higher in treated patients compared to untreated patients. Five different types of bacteria including Staphylococcus and Streptococcus were more abundant in the stomachs of treated children; finding these particular bacteria may be of clinical importance as some species of Staphylococcus and Streptococcus have been associated with respiratory symptoms.
“We did not find similar results in terms of the prevalence of growth or the abundance of bacteria in the bronchoalveolar lavage fluid of these treated children although we did find 2 genera of bacteria whose concentrations were highly correlated between the gastric and lung fluid suggesting possible exchange between these 2 sites,” Dr Rosen said.
Acid suppression results in changes in gastric microflora with increasing amounts of bacteria, and there may be some subtle upstream effects in lung flora, explained Dr Rosen.
“While acid suppression may be very useful in controlling typical reflux symptoms such as chest pain or heart burn, the potential benefits must be weighed against the risks, especially in patients with underlying pulmonary symptoms or in immunocompromised patients,” she said. “More patient education about the risks of using acid suppression is needed.”
Guidance on off-label drug use in pediatric population updated