Correspondence
Bismuth in Infants with Watery Diarrhea
N Engl J Med 1993; 329:1742-1743December 2, 1993
- Article
To the Editor:
Figueroa-Quintanilla et al. (June 10 issue)1 state that bismuth subsalicylate could be a useful, safe, and cost-effective adjunct to oral rehydration and nutritional therapy in children with acute watery diarrhea. We are surprised that they did not consider the risk of Reye's syndrome, since the use of aspirin, a salicylate-containing drug, has been associated with an increased risk of this syndrome. Whether or not there is an increased risk of Reye's syndrome with the use of bismuth subsalicylate remains to be determined. The syndrome, however, has been reported in patients whose only exposure to salicylates was to bismuth subsalicylate2. Barrett, who works at the Centers for Disease Control and Prevention, has written that it is prudent to avoid all compounds containing salicylate for presumed viral illnesses (including most cases of gastroenteritis) in children3. Thus, the routine use of bismuth sabsalicylate as adjunctive therapy for gastroenteritis with three or more watery stools in a 24-hour period (the protocol used in the study by Figueroa-Quintanilla et al.) may be unsafe.
3 ReferencesJon S. Abramson, M.D.
Laurence B. Givner, M.D.
Charles R. Woods, Jr., M.D.
Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 271571
Figueroa-Quintanilla D ,Salazar-Lindo E ,Sack RB , et al. A controlled trial of bismuth subsalicylate in infants with acute watery diarrheal disease. N Engl J Med 1993;328:1653-1658
Full Text | Web of Science | Medline2
Hurwitz ES ,Barrett MJ ,Bregman D , et al. Public Health Service study of Reye's syndrome and medications: report of the main study. JAMA 1987;257:1905-1911[Erratum, JAMA 1987;257:3366.]
CrossRef | Web of Science | Medline3
Barrett MJ . Association of Reye's syndrome with use of Pepto-Bismol (bismuth subsalicylate). Pediatr Infect Dis 1986;5:611-611
To the Editor:
Figueroa-Quintanilla et al. rightly highlight the need to assess the role of a potential antidiarrheal drug such as bismuth subsalicylate by using it in conjunction with a proper regimen for diarrhea in children (e.g., one consisting of oral rehydration therapy and early feeding). However, a lactose-free formula was used in their trial. Are the authors endorsing the use of lactose-free formula as the optimal regimen for feeding infants and children with acute watery diarrhea? As Snyder points out in his editorial (June 10 issue),1 the cost of therapy is an important consideration, particularly in the underdeveloped world. If special formulas were to be used as yet another adjunctive therapy for managing acute diarrheal diseases in childhood, the cost of such a strategy would escalate beyond our wildest predictions.
Are we again being led away from the simple, rational, and effective treatment of acute diarrhea endorsed by the World Health Organization and the United Nations Children's Fund (UNICEF)?
1 ReferencesErnesto Guiraldes, M.D.
Pontificia Universidad Catolica de Chile, Santiago, Chile1
Snyder JD . Can bismuth improve the simple solution for diarrhea? N Engl J Med 1993;328:1705-1706
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We share the concern expressed by Dr. Abramson and colleagues about the potential relation between nonaspirin salicylates and Reye's syndrome. After reviewing the medical literature and discussing the matter with three independent ethical review committees, we felt that there were no data that suggested any association. In the study cited by Dr. Abramson et al., there was only one patient with Reye's syndrome who had received bismuth subsalicylate. It should also be pointed out that all the children in our study were less than 5 years of age, and most were less than 2 years of age; the mean age was 13.4 months -- an age at which Reye's syndrome is very unusual. We agree, however, that an awareness of the possibility of an association is important, particularly if the use of bismuth subsalicylate becomes widespread.
In response to Dr. Guiraldes's comments about therapy, we did not mean to imply that lactose-free formula should be used routinely in the management of diarrhea. It was used in our study to eliminate the confounding problems of lactose malabsorption that might have made the stool outputs more variable. We also agree that the costs of therapy are tremendously important, particularly in developing countries. We in no way wish to detract from the “simple, rational, and effective” treatment (the use of oral rehydration solutions and early feeding) promoted by the World Health Organization and UNICEF. In fact, we have been very much involved in establishing the usefulness of this approach. Bismuth subsalicylate shows the promise of being a useful adjunct to treatment by reducing stool output and the duration of diarrhea. We do not know, however, whether lower doses might also be effective -- a possibility that would further decrease the cost of therapy. We are planning studies to see whether bismuth subsalicylate is useful in preventing (or treating) persistent diarrhea, which is also a major problem in the developing world.
Eduardo Salazar-Lindo, M.D.
Universidad Peruana Cayetano Heredia, Lima, PeruR. Bradley Sack, M.D., Sc.D.
Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD 21205Dante Figueroa-Quintanilla, M.D.
Instituto Nacional de Salud del Nino, Lima, Peru- Citing Articles (2)
