Athena's Pages

(Athena stands for abbreviation of Abstracting and Thoughtful Evaluation of Neonatal Articles; but it is also personified by the contributor. Like Athena of Greek mythology, she distills wisdom from published literature) Necrotizing enterocolitis (NEC) is a common surgical emergency in neonates. The list of etiological agents of NEC is already exhaustive. A recent paper published in Pediatrics adds another factor to this long list [1]. Italian researchers have shown that Ranitidine could cause NEC in neonates. Although Ranitidine has not been approved by FDA for neo-nates, it is frequently used off-label to manage gastro-esophageal reflux and surgical stress. In fact, Athena used to prescribe it to all neonates, including NEC patients, who are kept nil per oral with an intent to prevent mucosal ulcer-ation. Terrin et al have shown that Athena may be wrong in her approach. They evaluated 274 neonates with very low birth weight of 401 to 1500 g. Among them 91 had received Ranitidine and 183 had not. They excluded newborn with immunodeficiency, malformations of gut, NEC prior to admission , critical illness, ranitidine therapy less than 7 days and hospitalization fewer than 8 weeks. Caregivers who determined the indication, dosage and duration of ranitidine therapy were blinded as to the nature of study. NEC was diagnosed if the clinical and radiological features correspond to Bell-Stage II or more. Other risk factors of NEC such birth weight, gestational age, Apgar score, critical risk index for babies (CRIB) score, presence of central venous access port, vascular malformation such as ductus arteriosus and mechanical ventilation have all been controlled and matched between the groups. Nearly 25% of neonates receiving Ranitidine developed sepsis as compared to only 9% who did not. Escherichia, Pseudomonos and Klebsiella infections were significantly more common in Ranitidine group. NEC occurred in 10% of newborn treated with Ranitidine while it was so in only 2% of those who were not exposed to the drug. The risk of NEC was independent of the dosage and duration of Ranitidine therapy. Mortality was 6 times higher in Ranitidine group. Athena acknowledges the logics of the study conclusion. Gastric acidity is one of the important non-immunological defense mechanisms of human body. Ranitidine induced hypochlorhydria promotes colonization of pathogenic flora in neonatal gut thereby, may predispose to sepsis and NEC. But it is perplexing as to why the two groups did not differ in the incidence of certain opportunistic pathogens such …