Guideline adherence limits use of acid-suppressing meds in NICU

Last Updated: 2017-11-21

By Will Boggs MD

NEW YORK (Reuters Health) - Implementing an evidenced-based guideline can significantly reduce the use of acid-suppressing medications in the neonatal intensive care unit (NICU), researchers report.

"More and more evidence is emerging regarding effects of acid-suppressing agents (and other medications such as antibiotics) on neonatal health, immunity, and the microbiome," Dr. Asimenia Angelidou from Boston Children's Hospital, Harvard Medical School, in Boston, told Reuters Health by email. "It is important to reassess our practices and continue to provide education to providers caring for newborns in similar settings, such as pediatric/cardiac ICUs."

Acid-suppressing medications are commonly prescribed in the NICU for a variety of conditions despite the lack of high-quality evidence for many of those indications. Recent guidelines have recommended against routine use of proton-pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) in both term and preterm infants.

Dr. Angelidou's team developed a guideline for prescribing acid-suppressing medications for NICU infants <1 month corrected age. The aim was to reduce the number of non-indicated prescriptions from a baseline of 7.5 per month to 4 per month.

The interventions included:

- Establishing evidence-based criteria for PPI/H2RA prescription and implementing them as a clinical practice guideline;

- Educating staff; and

- Encouraging staff buy-in and guideline uptake.

The number of non-indicated prescriptions per month, the primary outcome measure, decreased from 7.5 before guideline implementation to 2.5 during the first 9 months post-implementation to 0 during the next 6 months post-implementation, according to the November 21 Pediatrics online report.

After accounting for the trend toward increasing prescription of PPIs/H2RAs during the baseline period, this represented an average 7.9 fewer prescriptions per month than expected immediately after implementation and 12.8 fewer per month in the final study period.

Moreover, the ratio of PPI/H2RA patient-days to total patient-days (a measure of the overall burden of exposure to acid-suppressing medications) declined by more than half, from 44.7% at baseline to 20.2% post-implementation.

There was also a decrease in the total (indicated plus non-indicated) prescriptions of PPIs/H2RAs associated with implementing the guideline.

"Successful implementation largely depends on the culture of a respective unit around prescription of acid-suppressing medications, as well as on investment of each unit's leadership in implementing a guideline for their optimal use," Dr. Angelidou said.

"The greatest challenge was to overcome anecdotal experiences of individuals regarding use of acid-suppressing medications and optimize use of those medications for certain conditions where there is at least some supportive evidence for their efficacy/need," she said. "The patient population in our NICU is quite complex and prescription of acid-suppressing medications is considered 'least harmful' compared to other interventions. Instituting a medication trial was key in proving no objective gains for certain conditions, such as gastroesophageal reflux, when acid-suppressants are commonly used."

"Providing real-time feedback to frontline providers regarding their practices and celebrating milestones together as a unit were also instrumental to compliance with the guideline," she said.

"We are hoping that similar initiatives will emerge in other ICUs to ensure optimal use of medications in the neonatal population," Dr. Angelidou concluded. "An impactful further step would be providing education to pediatricians in the community."

Dr. Jonathan Slaughter from The Ohio State University College of Medicine and Nationwide Children's Hospital, in Columbus, who has described the frequent use of PPI/H2RAs at U.S. children's hospitals, told Reuters Health by email, "Education is key. Acid suppressives have been prescribed to infants for many years, on the assumption that treatment is beneficial. Now that increasing evidence has shown that acid-suppressive treatment is clearly not helpful for certain diagnoses, re-education of neonatal physicians and nurses is needed to change engrained but potentially harmful acid-suppressive prescribing practices."

"Quality improvement projects to reduce acid-suppressive treatment of hospitalized newborns for diagnoses where treatment is clearly not indicated, including nil per os (NPO) status, feeding intolerance, neonatal apnea and bradycardia, and uncomplicated gastroesophageal reflux, can successfully and safely reduce unnecessary and potentially harmful, acid-suppressive treatment," he concluded.

SOURCE: http://bit.ly/2z7v33h

Pediatrics 2017.