By Randolph Fillmore
Childhood asthma is an increasingly common respiratory condition involving chronic inflammation in the lungs. Inflammation from asthma can cause airways to close, bringing on constant coughing, shortness of breath, and rapid breathing with wheezing or whistling sounds. When asthma attacks are severe requiring hospitalization to the intensive care unit, referred to as “critical asthma” (CA), intravenous steroids and other interventions to treat the underlying inflammation are urgently required.
According to Alexa Roberts, M.D., who recently completed her three-year residency at Johns Hopkins All Children’s Hospital, children hospitalized for CA and admitted to the pediatric intensive care unit (PICU) are commonly prescribed stress ulcer prophylaxis (SUP) to prevent gastrointestinal bleeding that has been previously attributed to corticosteroids.
However, while SUP is routinely and increasingly administered to children receiving corticosteroids for critical asthma in the PICU, the incidence of clinically relevant bleeding and potential risk reduction for bleeding as a result of prophylaxis administration had not been investigated in pediatrics or adults.
“We wanted to describe the trends for SUP prescribing and investigate the rates of clinically relevant GI bleeding, gastritis, and SUP-related complications for those with and without SUP exposure,” Roberts explains. “I was already a little suspicious of the broad way in which SUP has been applied.”
To get answers, Roberts and her fellow researchers queried the Pediatric Health Information System (PHIS) registry to identify national trends in SUP prophylaxis prescribing over most of a decade, and to determine the rates of major GI bleeding and clinically symptomatic gastritis among children hospitalized for CA.
“We hypothesized clinically relevant GI bleeding and gastritis were rare and no different for those who were and weren’t prescribed SUP,” says Anthony A. Sochet, M.D., M.Sc., an assistant professor of Anesthesiology and Critical Care Medicine at The Johns Hopkins University who is based in the Pediatric Critical Care Medicine Division at Johns Hopkins All Children’s in St. Petersburg, Florida.
Looking into rates of SUP prescribing recorded in the PHIS from 2010 to 2019, the researchers found that, in 2019, SUP prescribing rates were 42.1 percent, with the practice of prescribing SUP having increased by an average of 1.9 percent annually since 2010.
Roberts, Sochet and their Johns Hopkins All Children’s colleagues initiated a retrospective, multicenter cohort study using the Pediatric Hospital Information System registry. The PHIS database contains inpatient, emergency department, ambulatory, surgical, and observational and other encounter-level data from more than 50 not-for-profit, tertiary care pediatric hospitals affiliated with the Children’s Hospital Association.
“We elected to do a national study on this topic and review a registry of thousands of children with critical asthma to get a national picture of variation in care related to SUP and the rate of clinically relevant bleeding events, which is what clinicians are trying to prevent when prescribing these agents,” explains Roberts.
The researchers used available data from 42 children’s hospitals from 2010 to 2019 that included those children 3 to 17 years of age admitted to pediatric intensive care units for CA treatment. Their study, noted as being the largest cohort study to date assessing children hospitalized for critical asthma over a 10-year period, was recently published in the journal Pediatrics.
Study Results Suggest a Targeted, Risk-Based Approach
Of 30,177 children studied, 10,387 (34.4 percent) received SUP. No episodes of GI bleeding were recorded. One subject developed a gastric ulcer and 32 (0.1 percent) gastritis during their hospitalization. Prescribing varied by institution (range: 5.5 to 97.2 percent), but without correlation to hospital admission volumes for CA. Extremely rare rates of SUP-related complications were noted.
Importantly, they discovered that no episodes of GI bleeding were recorded. Gastritis and GI ulceration diagnoses were extremely rare and not detectably different for children who did — or did not — receive SUP.
Given the data, the researchers noted that prescribing SUP solely for corticosteroid exposure may be “unwarranted” and they advocated for a “targeted approach” to prescribing SUP among children with predisposing conditions that increase their likelihood for GI-related bleeding. They also concluded that unless SUP was targeted to those at highest risk, SUP may cause more harm than benefit.
“This study, although observational, suggests the common practice of using stress ulcer prophylaxis for children hospitalized with CA is likely unwarranted and may even expose children to additional risk rather than benefit,” says Sochet. “This means that clinicians should risk-stratify patients regarding their risk of gastric stress ulcer rather than ‘blanket’ prescribing acid suppressive therapy in children hospitalized for critical asthma who are receiving systemic corticosteroids. Until a randomized clinical trial is performed to further validate our findings, Dr. Roberts’ study will be invaluable to physicians and health care teams as they care for pediatric patients hospitalized with CA.”
The Physician as Researcher
Roberts, the study’s lead author, was recently recognized as both “Resident of the Year” and “Resident Scholar of the Year” at the Johns Hopkins All Children’s Residency Program 2022 graduation.
“I was honored and shocked to get both awards,” Roberts says as she begins a three-year Pediatric Critical Care Medicine fellowship, also at Johns Hopkins All Children’s.
Roberts said she values both caring for critically ill children and engaging in meaningful research that can help critically ill children get well.
“I love pediatrics,” says Roberts, who is the mother of two children, ages 3 years and 4 months. “This is my dream job. I always wanted to work in a large medical center, especially a teaching institution, and treat critically ill children. In my residency, I saw children in the emergency department, in the PICU, and on the floor after they stepped down from the PICU. It’s incredibly satisfying to see pediatric patients recover.”
Roberts, who conceptualized the study, contributed to the interpretation of results, drafted the initial manuscript, and reviewed and revised the manuscript before submission, credits her fellow researchers, including Sochet and John Morrison, M.D., Ph.D., who specializes in the care of hospital patients as a pediatric hospitalist in the Department of Medicine at Johns Hopkins All Children’s Hospital.
“My residency at Johns Hopkins All Children’s was great,” she says. “Dr. John Morrison, who runs the scholar program, and Dr. Sochet, who served as senior author on the study, have been wonderful mentors. Dr. Sochet’s interests and my interests came together on this issue. I have been extremely fortunate to work in a place where I can continue to grow and thrive as a physician, as well as a person.”
She also credits her experience in medical school at the University of Arizona for helping her prepare for the roles of both physician and researcher.
“From a position of humility and pride,” Sochet states, “Dr. Roberts's productivity and momentum highlights both her unwavering character and the result of meticulous career development guided by the Office of Medical Education at Johns Hopkins All Children’s Hospital (both from the Pediatric Residency Program and in our Critical Care Fellowship).”