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Prophylactic acid suppressants in children in the intensive care unit: a systematic review with meta-analysis and
Martine M Jensen1, Søren Marker1,2, Hien Q Do1
1Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Insights
Stress ulcer prophylaxis (SUP) in critically ill children showed no significant difference in mortality or bleeding. However, the evidence is very low quality, meaning benefits and harms remain uncertain.
Area of Science:
- Pediatric critical care medicine
- Gastroenterology
- Pharmacology
Background:
- Critically ill children face risks of stress-induced gastrointestinal ulceration.
- Acid suppressants are commonly used in intensive care units despite uncertain benefits and harms.
- This review assesses the patient-important benefits and harms of stress ulcer prophylaxis (SUP) in pediatric intensive care.
Purpose of the Study:
- To systematically review the evidence on stress ulcer prophylaxis (SUP) in critically ill children.
- To evaluate the benefits and harms of acid suppressants (histamine-2-receptor antagonists or proton pump inhibitors) versus placebo or no prophylaxis.
- To inform clinical decision-making regarding SUP in pediatric intensive care.
Main Methods:
- Systematic review adhering to PRISMA, Cochrane Handbook, and GRADE guidelines.
- Inclusion of randomized clinical trials comparing SUP with placebo/no prophylaxis in pediatric intensive care.
- Primary outcomes: all-cause mortality and overt gastrointestinal bleeding. Secondary outcomes: serious adverse events, hospital-acquired pneumonia, and others.
Main Results:
- Seven trials with 504 children were included.
- No statistically significant differences were found for all-cause mortality, overt gastrointestinal bleeding, or hospital-acquired pneumonia.
- Trial sequential analysis could not draw firm conclusions; certainty of evidence was rated as 'very low' for all outcomes.
Conclusions:
- Acid suppressants for stress ulcer prophylaxis in critically ill children did not show a significant difference in mortality, bleeding, or pneumonia compared to placebo.
- The evidence base is of very low quality and quantity.
- There is currently no firm evidence to support or refute the benefits or harms of stress ulcer prophylaxis in this population.
Background:
Critically ill children are at risk of stress-induced gastrointestinal ulceration. Acid suppressants are frequently used in intensive care units even though there is uncertainty about the benefits and harms. With this systematic review, we aimed to assess patient-important benefits and harms of stress ulcer prophylaxis (SUP) in children in intensive care.
Methods:
We conducted the review according to the PRISMA statement, the Cochrane Handbook, and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). We included randomised clinical trials comparing SUP with histamine-2-receptor antagonists or proton pump inhibitors vs placebo/no prophylaxis in children admitted for intensive care. Primary outcomes were all-cause mortality and overt gastrointestinal bleeding. Secondary outcomes were serious adverse events, hospital-acquired pneumonia, Clostridium difficile enteritis, myocardial ischemia, acute kidney injury and quality of life.
Results:
We included a total of seven trials (n = 504) with eight trial comparisons. We found no statistically significant difference in all-cause mortality (relative risk (RR) 1.43, 95% confidence interval (CI) 0.86-2.37), overt gastrointestinal bleeding (RR 0.75, 95% CI 0.42-1.35) or hospital-acquired pneumonia (RR 1.18, 95% CI 0.77-1.82) between SUP vs placebo/no prophylaxis. No trials reported on remaining secondary outcomes. TSA was unable to draw firm conclusions for all outcomes and certainty of evidence for all outcomes was "very low."
Conclusions:
We found no difference in all-cause mortality, overt gastrointestinal bleeding or hospital-acquired pneumonia in children in intensive care receiving acid suppressants compared with placebo/no prophylaxis. However, the quantity and quality of evidence was very low with no firm evidence for benefit or harm.
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