Tardive dyskinesia associated with use of metoclopramide in a child

The Safety of Metoclopramide in Children: A Systematic Review and Meta-Analysis

INTRODUCTION

Metoclopramide is recommended for adults with breakthrough or refractory chemotherapy-induced nausea and vomiting (CINV) and for CINV prophylaxis in children. The drug regulatory agencies of Canada and the EU have revised the labelling of metoclopramide to contraindicate its use in children aged <1 year and to caution against its use in children aged <5 years and its duration of use beyond 5 days.

OBJECTIVE

This review describes the safety of metoclopramide in children when given for any indication.

METHODS

We conducted electronic searches in MEDLINE and Embase as of 9 March 2015. All studies in English reporting adverse effects associated with the use of metoclopramide in children (aged ≤18 years) were included. Adverse effects that had a cumulative incidence of at least 1 % and were reported in prospective studies were synthesized.

RESULTS

A total of 108 (57 prospective) studies involving 2699 patients (2745 metoclopramide courses) were included. The most common adverse effects reported in prospective studies of metoclopramide in children were extrapyramidal symptoms (EPS; 9 %, 95 % confidence interval [CI] 5-17), diarrhea (6 %, 95 % CI 4-9), and sedation (multiple-dose studies: 6 %, 95 % CI 3-12). Dysrhythmia, respiratory distress/arrest, neuroleptic malignant syndrome, and tardive dyskinesia were rarely associated with metoclopramide use.

LIMITATIONS

The definitions of adverse effects reported in the included studies were heterogeneous, and the risk of bias in most studies was moderate.

CONCLUSIONS

The most commonly reported adverse effects associated with the use of metoclopramide in children-EPS, diarrhea, and sedation-were reversible and of no long-term significance. Adverse effects that were life threatening or slow to resolve were rarely associated with its use in children.

Integrative Treatment of Reflux and Functional Dyspepsia in Children

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are common problems in the pediatric population, with up to 7% of school-age children and up to 8% of adolescents suffering from epigastric pain, heartburn, and regurgitation. Reflux is defined as the passage of stomach contents into the esophagus, while GERD refers to reflux symptoms that are associated with symptoms or complications-such as pain, asthma, aspiration pneumonia, or chronic cough. FD, as defined by the Rome III classification, is a persistent upper abdominal pain or discomfort, not related to bowel movements, and without any organic cause, that is present for at least two months prior to diagnosis. Endoscopic examination is typically negative in FD, whereas patients with GERD may have evidence of esophagitis or gastritis either grossly or microscopically. Up to 70% of children with dyspepsia exhibit delayed gastric emptying. Treatment of GERD and FD requires an integrative approach that may include pharmacologic therapy, treating concurrent constipation, botanicals, mind body techniques, improving sleep hygiene, increasing physical activity, and traditional Chinese medicine and acupuncture.

Management of paediatric GERD

Paediatric GERD is complicated to manage, as symptoms are diverse and often difficult to interpret. In infants, regurgitation is a common physiological condition. Nevertheless, when it occurs frequently (>4 times per day) and causes the infant distress, parents often seek medical help. In children 2-10 years of age, GERD is often considered to cause extra-oesophageal symptoms, despite the absence of hard evidence. Diagnostic investigations often lack solid validation and the signs and symptoms of GERD overlap with those of cow's milk protein allergy and eosinophillic oesophagitis. Reassurance, dietary treatment and positional adaptations are recommended for troublesome infant reflux. Anti-acid medication, mainly PPIs, is over-used in infants even though, in many children, reflux is not an acid-related condition. Moreover, evidence is increasing that PPIs cause adverse events such as gastroenteritis and respiratory tract infections. Management in children older than 10 years is similar to that in adults. Using prokinetics to treat nonerosive reflux disease remains only a promising theoretical concept, as no such molecule is currently available. Today, the adverse effects of each prokinetic molecule largely outweigh its potential benefit. Laparoscopic surgery is indicated in children who have life-threatening symptoms or in cases of drug dependence.

Baclofen for the treatment of pediatric GERD

BACKGROUND AND AIM

Baclofen, a γ-aminobutyric acid receptor agonist, has been shown to reduce the episodes of gastroesophageal reflux (GER) by reducing the incidence of transient lower esophageal sphincter relaxations. Although baclofen has been shown to reduce reflux symptoms in adults, data in pediatric patients are limited. The aim of the study was to evaluate the efficacy of baclofen in children with refractory GER.

METHODS

Medical charts of patients 1 to 18 years of age treated with baclofen for persistent GER symptoms were reviewed retrospectively. Short-term (at first clinic visit) and long-term (12 months) clinical responses were assessed.

RESULTS

A total of 53 patients were included in the final analysis. The mean duration of illness was 1.5 years and the mean age was 6.1 years. All of the patients were taking either once- (53%) or twice-daily (47%) doses of proton pump inhibitors (PPIs) at the time of initiation of baclofen. Thirty-five (66%) patients experienced a significant reduction in clinical symptoms at their first follow-up visit. In the remaining 18 patients, however, baclofen was stopped because of either no response (n = 15) or adverse events (n = 3). A total of 27 patients continued treatment and were assessed for long-term response. Of those, 22 (81%) had a sustained response to baclofen at 12 months, whereas 5 (19%) lost response. We recognized no clinical characteristic differences between those with and without a response to baclofen at either time point.

CONCLUSIONS

Baclofen can be used as supplemental therapy to proton pump inhibitors in children with refractory GER; however, prospective trials are needed to further validate our results and assess safety.

Tardive dyskinesia after short-term treatment with oral metoclopramide in an adolescent

CASE

The objective of this case report is to report the development of tardive dyskinesia in an African-American adolescent male after short-term treatment with metoclopramide 10 mg orally three times daily secondary to delayed gastric emptying. The patient developed symptoms of tardive dyskinesia after 2 days of therapy with metoclopramide. Metoclopramide was discontinued and diphenhydramine 50 mg was initially administered intravenously followed with 25 mg orally every 4 hours as needed. While there are case reports of drug-induced tardive dyskinesia after intravenous administration of metoclopramide, this is to our knowledge the first report of tardive dyskinesia after short-term treatment with oral metoclopramide in an adolescent.

CONCLUSION

Awareness of the risk of development of this adverse effect even with short-term treatment with metoclopramide and in younger patients is important.

A quality improvement approach to optimizing medication use in the neonatal intensive care unit

Despite many years of heavy use in premature and critically ill newborns, surprisingly few medications have been rigorously tested in neonatal multicenter randomized clinical trials. Little is known about the pharmacology of these drugs at various birth weights, gestational ages, and chronologic ages. This article describes a quality improvement approach to evaluating and improving neonatal intensive care unit (NICU) medication use, with an emphasis on adaptation of drug use to the specific clinical NICU context and use of system-based changes to minimize harm and maximize clinical benefit.

Canadian guidelines for the evidence-based treatment of tic disorders: pharmacotherapy

This article seeks to provide the practising clinician with guidance on the pharmacological management of tic disorders in children and adults. We performed a systematic review of the literature on the treatment of tic disorders. A multi-institutional group of 14 experts in psychiatry, child psychiatry, neurology, pediatrics, and psychology engaged in a consensus meeting. The evidence was presented and discussed, and nominal group techniques were employed to arrive at consensus on recommendations. A strong recommendation is made when the benefits of treatment clearly outweigh the risks and burdens, and can apply to most patients in most circumstances without reservation. With a weak recommendation, the benefits, risks, and burdens are more closely balanced, and the best action may differ depending on the circumstances. Based on these principles, weak recommendations were made for the use of pimozide, haloperidol, fluphenazine, metoclopramide (children only), risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, topiramate, baclofen (children only), botulinum toxin injections, tetrabenazine, and cannabinoids (adults only). Strong recommendations were made for the use of clonidine and guanfacine (children only). While the evidence supports the efficacy of many of the antipsychotics for the treatment of tics, the high rates of side effects associated with these medications resulted in only weak recommendations for these drugs. In situations where tics are not severe or disabling, the use of a medication with only a weak recommendation is not warranted. However, when tics are more distressing and interfering, the need for tic suppression to improve quality of life is stronger, and patients and clinicians may be more willing to accept the risks of pharmacotherapy.

Tardive dyskinesia and withdrawal emergent syndrome in children

Tardive dyskinesia (TD) is a well-recognized and sometimes permanent adverse effect of treatment with dopamine receptor-blocking drugs (DRBDs), also referred to as neuroleptics. This iatrogenic disorder has been well characterized in adults, but not extensively studied in children. Withdrawal emergent syndrome (WES) is another pediatric movement disorder related to the use of DRBDs. TD and WES are among the most feared adverse effects of DRBD treatment, and have important medical and legal implications. We review published studies of children under the age of 18 years who were exposed to DRBD to determine the clinical spectrum and estimate the possible prevalence of TD and WES. We particularly wish to draw attention to the phenomenology, clinical course and treatment of these childhood-onset disorders. Although avoiding DRBDs is the best strategy for minimizing the risk of TD and WES, physicians who evaluate children exposed to DRBDs must be vigilant and recognize the early symptoms and signs of these syndromes to provide appropriate clinical management.

Prescription trends for treatment of paediatric gastroenteritis at a Japanese hospital between 1997 and 2007

OBJECTIVE

We aimed to investigate recent trends in prescriptions for the treatment of paediatric gastroenteritis in Japan over a 10-year period (1997-2007).

METHODS

In this retrospective cohort study, we collected data for 2295 prescriptions for 1241 putative cases of paediatric gastroenteritis, which were treated between 1997 and 2007 at Hamamatsu University Hospital, Hamamatsu, Japan.

RESULTS

The most frequently prescribed drugs were probiotics (n = 621), followed by anti-emetics (n = 474). In most years between 1997 and 2007, more cases were treated with probiotics than with any other drug type (30.6-63.3% of cases), with the percentage increasing between 2005 and 2007. In contrast, the frequencies of anti-emetic and antipyretic prescriptions remained fairly stable, and prescriptions for antibiotics decreased slightly over the study period. Anti-emetics were commonly used in this hospital.

CONCLUSION

Although experimental evidence upon which to base recommendations is lacking, Japanese evidence-based guidelines are critical for improving the quality of treatment of paediatric gastroenteritis.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Domperidone versus cisapride in the treatment of infant regurgitation and increased acid gastro-oesophageal reflux: a pilot study

AIM

Although domperidone is used frequently to treat infant regurgitation, efficacy data are scarce. Cisapride was previously used in the same indication.

METHODS

Domperidone and cisapride were compared in an investigator-blinded, prospective comparative trial by evaluating (a) the frequency of regurgitation, (b) acid reflux and (c) cardiac side effects in infants regurgitating >4 times/day since >2 weeks and with reflux-associated symptoms of discomfort, after conservative treatment failure.

RESULTS

Within the first treatment week, the frequency of regurgitation decreased in both groups, more rapidly in the cisapride group: the median regurgitation decreased from 6.22 to 3.50 in the cisapride group versus from 4.80 to 3.70 in the domperidone group. The decrease in regurgitation was still significant after 1 month: cisapride from 6.22 to 1.55 versus domperidone from 4.80 to 1.25. However, the natural decrease in the incidence of regurgitation induced by age should also be considered. The median reflux index decreased after 1 month in the cisapride group from 3.60 to 1.75 versus from 2.70 to 2.45 in the domperidone group. One child treated with cisapride developed a significant QT prolongation.

CONCLUSION

The decrease in regurgitation was comparable in both groups, although acid reflux decreased more in the cisapride group. Cisapride induced QT prolongation in one infant.

Distonia aguda relacionada ao uso de bromoprida em pacientes pediátricos

OBJETIVO: Descrever dois casos de distonia aguda após uso de bromoprida em crianças e realizar revisão da literatura em relação aos mecanismos fisiopatológicos de indução de liberação extrapiramidal, sua sintomatologia e tratamento. DESCRIÇÃO DO CASO: Caso 1: adolescente de 13 anos com quadro de dor e hipertonia cervical associados a febre, náuseas e vômitos, com hipótese inicial de meningite. A investigação subsequente revelou que o quadro iniciou-se após ingestão de uma única dose de bromoprida. O paciente apresentou boa resposta ao tratamento com difenidramina, sem necessidade de coleta de líquor. Caso 2: Lactente de seis meses que desenvolveu sintomas graves de liberação extrapiramidal relacionados à superdosagem de bromoprida, com reversão rápida dos sintomas após administração de biperideno. COMETÁRIOS: Este é o primeiro relato de distonia aguda após uso de bromoprida em crianças. Embora muito utilizada no Brasil como agente pró-cinético e antiemético, nenhum estudo clínico até o momento demonstrou melhor perfil de segurança da bromoprida em relação aos demais antieméticos antagonistas da dopamina. Até que tais estudos sejam realizados, sugere-se cautela na prescrição de bromoprida. Medidas não-farmacológicas devem ser recomendadas no tratamento de vômitos e da doença do refluxo gastresofágico. Quando o tratamento farmacológico for indispensável, deve-se dar preferência a drogas com perfil de segurança mais bem estabelecido.

Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting

Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Acute gastroenteritis is usually self-limiting. Oral rehydration therapy (ORT) is effective and successful in the majority of patients. Vomiting is common at the outset of viral gastroenteritis and can limit the effectiveness of ORT. Treatment with newer anti-emetic medications has been reported to facilitate ORT and to minimize the risk of dehydration and the need for intravenous hydration and hospitalization. The role of anti-emetic medications in the treatment of gastroenteritis-related vomiting is not clear. Some physicians agree with the use of anti-emetic medications because vomiting is unpleasant and distressing for the child and parents alike, and because vomiting can increase the likelihood of dehydration, electrolyte imbalance, and the need for intravenous hydration or hospitalization. Several surveys have shown that anti-emetic medications are commonly prescribed in the treatment of pediatric gastroenteritis and that adverse events are uncommon. Efficacy studies of the newer anti-emetic medications are now available and reveal that some are effective and help facilitate ORT. Other physicians disagree with the use of anti-emetic medications because acute gastroenteritis is a self-limiting condition, vomiting might help rid the body of toxic substances, there was previously a relative lack of published evidence of clinical benefit, and there are potential adverse events associated with the use of an anti-emetic medication. Anti-emetic medications that are currently available include ondansetron, granisetron, tropisetron, dolasetron, ramosetron, promethazine, dimenhydrinate, metoclopramide, domperidone, droperidol, prochlorperazine, and trimethobenzamide. Randomized, placebo-controlled trials suggest that ondansetron is efficacious and superior to other anti-emetic medications in the treatment of gastroenteritis-related vomiting. A recent double-blind clinical trial showed that a single oral dose of ondansetron reduces gastroenteritis-related vomiting and facilitates ORT without significant adverse events. Ondansetron shows promise as a first-line anti-emetic, and judicious use of this agent might increase the success of ORT, minimize the need for intravenous therapy and hospitalization, and reduce healthcare costs. Ondansetron should be considered in situations where vomiting hinders ORT, but a larger randomized, placebo-controlled trial is necessary before the medication can be routinely recommended for the treatment of gastroenteritis-related vomiting in children.

Important Facts About Intestinal Feeding Tube Placement

Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.

The diagnosis and management of gastro-oesophageal reflux in infants

Gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD) occur frequently during the first months of life. Gastro-oesophageal reflux may be a primary gastro-intestinal motility disorder, but it may also be secondary to other conditions such as cow's milk protein allergy. Objective diagnosis can be difficult because there may be absence of correlation between history, results of pH monitoring and histology. Severe GORD may cause minor symptoms, and minor GOR may cause severe symptoms. Several different therapeutic interventions exist. Simply stated, thickened formula reduces regurgitation and alginates and proton pump inhibitors can be used to decrease acid GOR, depending on the severity of the GORD. Efficacy data of prokinetic drugs are either lacking or disappointing. Regarding side-effects, interest has been focused on cisapride, although other molecules have similar effects. Long-term side-effects such as the nutritional consequence of therapeutic management have been insufficiently studied, especially for the acid-reducing molecules.

Metoclopramide induced dystonia in children: two case reports

Metoclopramide is a dopamine antagonist that is widely used in gastroesophageal disease and chemotherapy-induced emesis in the paediatric population. It is also prescribed in nausea and vomiting caused by respiratory tract infections and enteritis in practice. The primary side-effect of the drug is extrapyramidal reactions with incidences as high as 25% in children. We report two cases, one of which was referred to our emergency department as encephalitis and the other as tetany, but which were just acute dystonic reactions caused by metaclopramide, even though the patients had used the drug in the recommended dosages. The adverse effects of the drug can be seen at normal doses. These dystonic reactions caused by metaclopramide can easily be confused with other diseases, because dystonia is not seen frequently in paediatric practice whatever the cause.

Emerging drugs in Tourette syndrome

Proper education of the patient is the first step in the treatment of Tourette syndrome (TS). Before deciding how to treat the patient, it is important to decide whether to treat the TS-related symptoms. Counselling and behavioural modification may be sufficient for those with mild symptoms. Medications, however, may be considered when symptoms begin to interfere with peer relationships, social interactions, academic or job performance, or with activities of daily living. Therapy must be individualised and the most troublesome symptoms should be targeted first. Antidopaminergic agents are clearly the most effective drugs in the treatment of tics. Although haloperidol and pimozide are the only drugs currently approved by the FDA for the treatment of TS, other dopamine receptor-blocking drugs and tetrabenazine, a dopamine depleting drug, as well as botulinum toxin injections, have been used to treat tics associated with TS. Carefully designed, comparative, longitudinal trials assessing the efficacy and adverse-effect profiles of these drugs, including tardive dyskinesia, are lacking. Selective serotonin reuptake inhibitors are recommended for the treatment of obsessive-compulsive behaviour: a common comorbidity. Psychostimulants, such as methylphenidate, are the treatment of choice for attention deficit hyperactivity disorder. Even though these drugs may transiently increase tics, this does not necessarily constitute a definite contraindication to the use of these drugs in patients with TS. Here, existing and emerging medical treatments in patients with tics and comorbid behavioural disorders associated with TS are reviewed.

Prokinetic drug therapy in children: a review of current options

OBJECTIVE

To review the pharmacology, safety, and efficacy of the prokinetic agents metoclopramide and erythromycin in children.

DATA SOURCES

English-language literature was accessed using MEDLINE (1970-June 2004) with metoclopramide, erythromycin, macrolides, gastroesophageal reflux, and gastrointestinal motility as the search terms.

STUDY SELECTION AND DATA EXTRACTION

Abstracts and original research articles were included. Preference was given to published controlled trials. Articles providing descriptions of pharmacology, safety, and effectiveness of metoclopramide and erythromycin for the treatment of gastroesophageal reflux (GER) were also used in this review.

DATA SYNTHESIS

Some authors advocate using a prokinetic agent along with acid suppression for treatment of GER in children. The 2 prokinetic agents most commonly used are erythromycin and metoclopramide. Erythromycin has numerous observational reports and controlled trials demonstrating its efficacy in improving feeding tolerance in children. Adverse drug reactions associated with its use were uncommon in prospective controlled trials. Few data support the use of metoclopramide for management of GER, and the potential adverse effects associated with its use need to be considered before prescribing.

CONCLUSIONS

The literature supports the use of erythromycin as a prokinetic agent. Many children with GER are adequately controlled with acid suppression alone; however, if use of a prokinetic agent is warranted, erythromycin in combination with acid suppression should be considered. Given the lack of prospective controlled studies demonstrating metoclopramide's efficacy and safety in the treatment of GER in children, metoclopramide should not be considered a treatment option.

Metoclopramide-induced tardive dyskinesia in an infant

We describe a 1-year-old girl who developed orofaciolingual stereotypy at age 2 months after a 17-day treatment with metoclopramide for gastroesophageal reflux. The stereotypy, documented by sequential videos, persisted for at least 9 months after the drug was discontinued. This patient represents the first documented case of tardive dyskinesia in an infant. We also review previous reports of tardive dyskinesia in children.

Mouvements anormaux d’origine médicamenteuse : les syndromes tardifs

Persistent drug-induced movement disorders (tardive syndromes) remain an important clinical problem and consist of a variety of involuntary movements appearing in a patient exposed to a dopamine-blocking agent. The current state of knowledge on this topic is summarised in this article. Clinical aspects (tardive dyskinesia, tardive dystonia and other forms), prevalence, risk factors, prevention and management are discussed.

Gastroesophageal reflux in children: pathogenesis, prevalence, diagnosis, and role of proton pump inhibitors in treatment

A substantial percentage of infants, children and adolescents experience gastroesophageal reflux disease (GERD) and its accompanying symptoms, as well as disease complications. The diagnosis of GERD in children is made based upon the child's history, and data derived primarily from pH monitoring tests and endoscopy. In those children with confirmed reflux disease, the options for management parallel those recommended in adult patients, with the first step consisting of lifestyle changes. Surgical procedures may also be performed; however, these are rarely recommended prior to an adequate course of pharmacologic therapy, and appropriate case selection is important. Among the current pharmacotherapeutic options available in the US, the prokinetic agents and the acid-inhibitory agents (histamine-2 receptor antagonists, proton pump inhibitors) are the most widely used. The clinical utility of the prokinetic agents has been limited by the recent withdrawal of cisapride from the US marketplace and the potential for irreversible central nervous system complications with metoclopramide. Numerous clinical studies performed in adults, and several studies involving children, have demonstrated that the proton pump inhibitors are more effective than the histamine-2 receptor antagonists in the relief of GERD symptoms and healing of erosive esophagitis. In children, omeprazole and lansoprazole may be administered as the intact oral capsule, or in those who are unable or unwilling to swallow, the granule contents of the capsule may be mixed with soft foods (e.g. apple sauce) or fruit drinks/liquid dietary supplements prior to oral administration with no detrimental effects on pharmacokinetics, bioavailability, or pharmacodynamics. Studies performed with omeprazole and lansoprazole in children have shown pharmacokinetic parameters that closely resemble those observed in adults. In over a decade of use in adults, the proton pump inhibitor class of agents has been found to have a good safety profile. Studies involving children have also shown these agents to be well tolerated. In numerous drug-drug interaction studies performed with these two proton pump inhibitors, relatively few clinically significant interactions have been observed.

Autosomal dominant infantile gastroesophageal reflux disease: exclusion of a 13q14 locus in five well characterized families

OBJECTIVES

A genetic locus for pediatric reflux was proposed on chromosome 13q14, but is unconfirmed in independent kindreds. We sought to test this locus in families with multiple affected infants from our database of well characterized infants with reflux.

METHODS

We screened the database for families with multiple affected infants. Affected proband phenotype required histological esophagitis; affected sibling/cousin phenotype required a threshold score on a diagnostic questionnaire. Screened families were reduced to five based on pedigree, consent, and phenotypic clarity. Linkage of the phenotype with the four previously reported markers (D13S218, D13S1288, D13S1253, and D13S263) was tested, using an autosomal dominant, 70% penetrance model. Linkage required logarithm-of-odds score > or = 3.

RESULTS

Of 54 individuals in the five probands' generation, 21 (39%) were affected based on questionnaire, of whom nearly one half also had histological confirmation of esophagitis. Linkage to the defined region was excluded for the five families by two-point LOD scores (-1.47 at D13S218, -1.32 at D13S1288, -3.43 at D13S1253, and -3.92 at D13S263) and by multipoint (multipoint LOD scores less than -2 between D13S218 and D13S263) linkage analysis. No family demonstrated even suggestive positive linkage (i.e., LOD score >1).

CONCLUSIONS

In five rigorously phenotyped families with autosomal dominant pattern infantile reflux, we excluded genetic linkage to the region of 13ql4 previously identified responsible for an autosomal dominant form of pediatric reflux. These results suggest genetic heterogeneity, possibly related to phenotypic heterogeneity, in familial pediatric gastroesophageal reflux disease.

Antiemetic use in pediatric gastroenteritis: a national survey of emergency physicians, pediatricians, and pediatric emergency physicians

The objective of this study was to review the use of antiemetics for pediatric gastroenteritis and to determine prescribing patterns of physicians. A mailed cross-sectional survey instrument was sent to randomly selected board-certified emergency medicine, pediatric, and pediatric emergency medicine specialists. A total of 1665 surveys were mailed, with 593 completed surveys returned (35.6% response rate). A majority of responders (60.9%) reported using antiemetics for pediatric gastroenteritis at least once in the past year, with a greater than 50% usage for all three specialty groups. Promethazine was the most commonly used antiemetic in all specialties, and per rectum the most common route of administration. Adverse reactions following a single dose of antiemetic were most frequently reported with prochlorperazine. The most common reason for antiemetic use was to prevent further dehydration. The most common concern regarding antiemetic use was potential for side effects. Occasional antiemetic use appears to be a common practice in treating pediatric gastroenteritis, regardless of specialty. Given the absence of literature on efficacy or safety, these drugs should be used only with careful consideration to potential side effects.

Gastroesophageal reflux in the neonate

Physiologic GER may be a maturational phenomenon, because infants outgrow this over time. Many aspects of GERD in neonates and young infants remain incompletely understood, however, particularly the pathophysiology and long-term problems in high-risk neonates. Diagnostic and therapeutic availability is vital in infants with GER and airway compromise, apnea events, or chronic lung disease. Although most infants improve with conservative therapy, there is a dire lack of ideal pharmacologic agents that work on all the mechanisms of GER with the least consequences. Studies that permit diagnosis not only of the disease but also of the causal mechanism, better feeding strategies, and prevention of morbidity from GERD will be beneficial.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Postfundoplication Complications in Children

The optimal "treatment" of postfundoplication complications is preoperative prevention of them. Nonreflux causes of the symptom prompting surgery should be carefully eliminated preoperatively. Failure to respond to optimal powerful antireflux pharmacotherapy suggests that GERD was not the cause of symptoms. Neurologic or respiratory disease, delayed gastric emptying or retching, short esophagus, and esophageal dysmotility may predispose patients to complications, and may require careful tailoring of the fundoplication. The optimal antireflux surgery, with a wrap neither too loose nor too tight, may require a nadir lower esophageal sphincter pressure of more than 5 mm Hg to prevent reflux, but less than some value to prevent dysphagia. This latter value may be approximately 10 mm Hg, but depends on swallowing parameters such as peristaltic pressure, lower esophageal sphincter opening diameter, swallowed bolus diameter, and other considerations. Infants may require a gastrostomy tube for venting because of their lower gastric compliance to deal with swallowed air. Children with delayed gastric emptying may benefit from pyloroplasty, but this is debated. When complications occur, re-evaluate the diagnosis and the competence of the fundoplication with barium fluoroscopy, endoscopy with histology, pH probe, and other modalities as indicated. Initially try conservative management of the patient's complications, including dietary and feeding modifications. Give a trial of antireflux pharmacotherapy for recurrent reflux or pharmacotherapy directed at the specific side-effect of the fundoplication if one is present. Consider endoscopically dilating a persistently tight wrap or surgically revising the fundoplication if it is suggested by the evaluation.

Management of supraesophageal complications of gastroesophageal reflux disease in infants and children

Therapy of supraesophageal manifestations of gastroesophageal reflux disease (GERD) in infants and children nearly always includes "lifestyle modifications" (conservative or nonpharmacologic therapy). Depending on the severity of the GERD manifestation, pharmacotherapy is often added. Although data to support the practice are not abundant, it is rational to begin with prokinetic pharmacotherapy and to add acid suppression if pathologic effects of acid contact with the esophagus or airway are suspected. Pathologic effects of acid produce most forms of supraesophageal GERD; the exception is infantile regurgitation, the most common example of supraesophageal GERD, which is often unaccompanied by either esophagitis or evidence of acid entry into the airway. Currently, fundoplication is rarely required for pediatric GERD, but the supraesophageal complications of GERD are more common indications for this surgery than the esophageal complications in children. Other management options for supraesophageal symptoms in children include delivery of nutrients by tube feeding slowly and continuously into the stomach or, better, small intestine. Short-term or trial tube feeding uses a transnasal tube, for example, for nasojejunal feeding; longer-term tube feeding is simplified by a gastrostomy, which can be placed relatively noninvasively using endoscopy or fluoroscopy.

Effect of prokinetic agents on ileal contractility in a rabbit model of gastroschisis

Intestinal hypomotility is a major problem after repair of gastroschisis. The authors assessed the effect of four clinically available prokinetic agents on intestinal contractility using a rabbit model of gastroschisis. Gastroschisis was surgically created at 24 days' gestation in fetal rabbits. At term, 10-mm ileal muscle strips were harvested, suspended in an organ bath, and stimulated with 10(-6) mol/L carbechol with and without each prokinetic agent: metoclopromide (1 x 10(-5) mol/L), cisapride (2 x 10(-5) mol/L), erythromycin (1 x 10(-5) mol/L), and octreotide (5 x 10(-5) mol/L). The effect of each agent on contractility was calculated as percent change from maximal response to carbechol alone. There were two control groups: sham operated fetuses, and maternal ileum. Metoclopromide was effective only in the adult rabbits. Cisapride improved contractility in newborns with gastroschisis, as well as in both newborn and adult control groups. Neither erythromycin or octreotide improved bethanechol-induced contractility in any of the animals. These data suggest that cisapride may be useful for treating hypoperistalsis in infants with gastroschisis. Clinical studies must be done to further pursue this finding.

Gynecomastia with metoclopramide use in pediatric patients

Gynecomastia and galactorrhea stemming from hyperprolactinemia have been reported in adults after the use of metoclopramide. We describe the cases of an adolescent with gynecomastia and an infant with gynecomastia and galactorrhea that were the result of metoclopramide therapy for gastroesophageal reflux disease.

Enteral feeding associated gastroesophageal reflux and aspiration pneumonia: a review

Hospital malnutrition continues to be a serious problem. Although enteral feeding of hospitalized patients is safe and less expensive than parenteral feeding, it is associated with side effects involving the gastrointestinal tract and respiratory systems.

Gastroesophageal reflux. Diagnostic and therapeutic approaches

The clinical challenge of determining the medical conditions that are associated with obvious symptoms of gastroesophageal reflux and what diagnostic tests are appropriate to define this relationship is substantial. To determine which infants may be suffering from pathologic conditions associated with subtle signs of gastroesophageal reflux is even more challenging. This determination is essential to avoid subjecting many healthy infants to costly and potentially invasive testing. This article focuses on the physiology, clinical presentations, diagnosis and evaluation, and therapy of gastroesophageal reflux.

Gastroesophageal reflux: one reason why baby won't eat

Gastroesophageal reflux (GER) is the movement of gastric contents retrograde into the esophagus. Sometimes the refluxate is seen as emesis, but often reflux is "silent," meaning that there are no discrete symptoms during an episode. In adults, the most common symptom of GER is heartburn, whereas in infancy excessive crying and malaise are symptoms that prompt investigation for GER, with or without esophagitis. Symptoms of esophagitis in infancy may include arching (hyperextension) of the torso and refusal of feedings. Tube feedings may be required to treat infants with failure to thrive who refuse oral feedings. Paradoxically, tube feedings increase the number of GER episodes. A hypothetical explanation for refusal of food in infancy is that pain with swallowing (odynophagia) or heartburn are consequences of peptic esophagitis. As a result, infants will learn to refuse food if it hurts or if they fear that it will hurt to eat. Another possible mechanism is visceral hyperalgesia, a neuropathic condition in which prior experience changes sensory nerves so that previously innocuous stimuli are perceived as painful. Some infants may have especially sensitive sensory nerves in the upper gastrointestinal tract, which predisposes visceral hyperalgesia to develop. Thus pain occurs from luminal distension or acid reflux in the absence of tissue damage. The evaluation of babies who won't eat includes a careful history and physical examination to exclude the possibility of chronic systemic illness. Refusal to feed is an unusual manifestation of a common condition: GER disease. The initial tests for GER usually include a barium swallow study to assess the upper gastrointestinal anatomy, endoscopy and esophageal biopsy to assess esophagitis, and an intraesophageal pH study, which is useful in "silent" reflux to quantitate the duration of esophageal acid exposure and to correlate discrete symptom episodes with periods of reflux. The treatment of infants and toddlers who refuse to eat because of pain resulting from visceral hyperalgesia or reflux esophagitis involves removing the pain associated with eating and making eating a pleasurable experience. Treatment for esophagitis may include maintaining an upright posture after meals and thickened feeds, medication to improve gastrointestinal motility or to decrease acid secretion, or fundoplication.