The use of cisapride in children. The North American Society for Pediatric Gastroenterology and Nutrition

Prokinetics prescribing in paediatrics: evidence on cisapride, domperidone, and metoclopramide

OBJECTIVES

Domperidone and metoclopramide are prokinetics commonly prescribed off-label to infants and younger children in an attempt to treat gastro-oesophageal reflux symptoms. Another prokinetic drug, cisapride, was used but withdrawn in 2000 in the United Kingdom because of serious arrhythmic adverse events. Medicines and Healthcare Products Regulatory Agency issued safety warnings for domperidone in May 2012 and restricted its indications. We report here national primary care prescribing trends and safety signals of these drugs in children.

METHODS

We used data from the General Practice Research Database between 1990 and 2006 for children <18 years. Descriptive statistics and Poisson regressions were performed to characterise prescribing trends. We examined safety signals in nested case-control studies.

RESULTS

The proportion of children <2 years old being prescribed one of the medications doubled during the study period. Prescriptions of domperidone increased 10-fold, mainly following the withdrawal of cisapride in 2000. Prescriptions of metoclopramide did not change significantly. Despite the increase in prescriptions of domperidone, no new safety signals were identified.

CONCLUSIONS

These data showed dramatic changes in prescribing of cisapride and domperidone despite the lack of good-quality supporting evidence. It is possible that these prescribing trends were influenced by published guidelines. Even if produced without robust efficacy and safety evidence, published guidelines can influence clinicians and consequently affect prescribing. Therefore, improving the evidence base on prokinetics to inform future guidelines is vital. The lack of new safety signals during this period would support the development of suitable powered clinical studies.

Pediatric gastroesophageal reflux disease

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.

Gastroesophageal reflux in infants and children

Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and the most frequent reason why infants are referred to the pediatric gastroenterologist, affecting as much as 30% of the pediatric population. Presenting features of GERD in infants and children are quite variable and follow patterns of gastrointestinal and extra-esophageal manifestations that vary between individual patients and may change according to age. Patients may be minimally symptomatic, or may exhibit severe esophagitis, bleeding, nutritional failure, or severe respiratory problems. GERD is also complex for the diagnostic techniques required to assess its repercussions or explain its origin. Although different abnormalities in motility variables, such as lower eso-phageal sphincter (LES) function, esophageal peristalsis and gastric motor activity can contribute to the development of GERD, the degree of esophageal acid exposure represents the key factor in its pathogenesis. Esophageal pH monitoring, based on both the detection of acid reflux episodes and the measurement of their frequency and duration, has been regarded as the most sensitive and specific diagnostic tool for diagnosing reflux disease. The aim of this paper is to give a concise review for the clinicians encountering this specific disease in infants and children.

Rational prescription of drugs within similar therapeutic or structural class for gastrointestinal disease treatment: Drug metabolism and its related interactions

AIM: To review and summarize drug metabolism and its related interactions in prescribing drugs within the similar therapeutic or structural class for gastrointestinal disease treatment so as to promote rational use of medicines in clinical practice.

METHODS: Relevant literature was identified by performing MEDLINE/Pubmed searches covering the period from 1988 to 2006.

RESULTS: Seven classes of drugs were chosen, including gastric proton pump inhibitors, histamine H₂-receptor antagonists, benzamide-type gastroprokinetic agents, selective 5-HT₃ receptor antagonists, fluoroquinolones, macrolide antibiotics and azole antifungals. They showed significant differences in metabolic profile (i.e., the fraction of drug metabolized by cytochrome P450 (CYP), CYP reaction phenotype, impact of CYP genotype on interindividual pharmacokinetics variability and CYP-mediated drug-drug interaction potential). Many events of severe adverse drug reactions and treatment failures were closely related to the ignorance of the above issues.

CONCLUSION: Clinicians should acquaint themselves with what kind of drug has less interpatient variability in clearance and whether to perform CYP genotyping prior to initiation of therapy. The relevant CYP knowledge helps clinicians to enhance the management of patients with gastrointestinal disease who may require treatment with polytherapeutic regimens.

Usage of the claim database of national health insurance programme for analysis of cisapride-erythromycin co-medication in Taiwan

PURPOSE

This study aimed to use the National Health Insurance Research Database, Taiwan for risk analysis of concomitant use of cisapride and erythromycin.

METHODS

The sample consisted of subjects identified in the Outpatient Sampling Database (OSD) and Longitudinal Health Insurance Database 2000 (LHID 2000), derived from the original claim data of the National Health Insurance Research Database, Taiwan.

RESULTS

According to the LHID 2000, a total of 464 individuals experienced 685 episodes of cisapride-erythromycin co-medication prescribed by 295 physicians, revealing a prevalence of 4.5% concomitant use, with higher prevalence in clinics (9.2%) than in other medical institutes (3.7-5.4%). Among the co-medication episodes, 81.9% and 61.2% were prescribed from the same health institutes and by the same physicians, respectively. No medical record of cardiac arrhythmias was found among these patients in 2001 and 2002, probably due to the fact that 78.9% of the 464 individuals were under age 16, 84.0% had short exposure duration (1-4 days) and 98.0% of the episodes were prescribed with a cisapride dose of less than 0.8 mg/kg/day.

CONCLUSIONS

Findings from this study suggest that there exists an urgent need for accreditation in terms of pharmacovigilance of clinical sites and their practicing physicians for the prevention of irrational concomitant prescription in Taiwan. Our findings also indicate that it is necessary to investigate other possible conditions of potentially dangerous co-medication in Taiwan and other developing countries.

Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children

Gastroesophageal reflux disease (GERD) presents in different ways in children, most commonly with vomiting, or with esophageal symptoms such as regurgitation, heartburn, or dysphagia. Extraesophageal symptoms and signs also frequently occur. Less well recognized is that abdominal pain is a relatively common mode of presentation. Although abdominal pain is common in school-aged children, GERD and other acid-related disorders such as peptic ulcer disease are relatively uncommon causes of such. A careful history will usually determine whether an acid-related disorder is in the differential diagnosis of abdominal pain. Early detection and treatment of GERD in children may prevent, attenuate, or heal complications such as failure to thrive or feeding refusal as well as pulmonary, ear-nose-and-throat disorders, erosive esophagitis, and peptic stricture. In children with persistent or severe symptoms and/or complications of GERD such as erosive esophagitis, the major treatment options are pharmacologic management with acid-suppressing medication, specifically proton pump inhibitors (PPIs), or antireflux surgery. For many patients, PPI treatment offers advantages over surgery. When given in adequate doses, PPIs can safely effect relief of GERD symptoms and healing of esophagitis in children. Antireflux surgery may work well in selected patients, but it carries significant risk of morbidity, including high failure rates, even in the short term. Some postoperative studies report that more than 60% of patients are back on medical treatment with proton pump inhibitors for recurrence of GERD symptoms, and a similar percentage have new symptoms that were not present before surgery. Death is uncommon but does occur and is an unacceptable risk in an otherwise healthy, low-risk individual. Laparoscopic surgery may have some disadvantages compared with open surgery, including a higher rate of redo operations. Studies show that many children undergo surgery for unclear indications, often with few preoperative diagnostic studies. The availability of highly effective medical therapy, together with more careful selection of patients for surgery, may result in better patient outcomes, with much lower operative rates.

Meta-analysis of randomized controlled trials on the benefits and risks of using cisapride for the treatment of gastroesophageal reflux in children

BACKGROUND AND AIM

Gastroesophageal reflux is a common problem in infancy. Cisapride is a commonly used therapy for gastroesophageal reflux in children. In view of recent concern regarding adverse effects this study aims to evaluate the benefits and risks of cisapride for the treatment of gastroesophageal reflux in children.

METHODS

A meta-analysis of randomized controlled trials of cisapride using a random-effects model.

RESULTS

Ten trials involving 415 children were identified. There was no evidence of a significant reduction in vomiting severity with cisapride as measured by a clinical score (five trials, standardized weighted mean difference -0.18; 95% confidence interval (CI) -0.51 to 0.15). Twenty-four-hour esophageal pH monitoring data showed the mean reflux index was significantly lower in the children treated with cisapride compared with controls (five trials, weighted mean difference -6.24; 95% CI -8.81 to -3.67). With cisapride treatment, there was no reduction in the mean number of reflux episodes lasting greater than 5 min (three trials, weighted mean difference -0.72; 95% CI -1.92 to 0.47) or in the number of children with esophagitis at final follow up compared with baseline (two trials, relative risk 0.80; 95% CI 0.40 to 1.61). There was no significant difference in reported side-effects or adverse events (six trials, relative risk 1.16; 95% CI 0.95 to 1.41).

CONCLUSIONS

No clinically important benefits of cisapride in children with gastroesophageal reflux have been demonstrated. Nor was there any evidence of adverse or harmful events.

Reported adverse drug events in infants and children under 2 years of age

OBJECTIVE

To characterize risks to infants and young children from drugs and biological products that were identified in spontaneous adverse event reports submitted to the US Food and Drug Administration.

METHODS

Of >500 000 MedWatch adverse event reports received by the Food and Drug Administration from November 1997 through December 2000, we identified 7111 reports about infants and children younger than age 2. The reports were analyzed for health outcome (eg, death, hospitalization, congenital anomaly), principal suspect drug, and whether the route of drug exposure was direct administration or through the mother in the perinatal period.

RESULTS

Drug therapy was associated with an average of 243 reported deaths annually over the 38-month study period, with 100 (41%) occurring during the first month of life and 204 (84%) during the first year. In 1432 (24%) reported adverse event cases of all levels of severity, exposure to the drug was from the mother during pregnancy, delivery, or lactation. Although 1902 different drugs, biological products, and other chemicals were identified in the reports, only 17 drugs or biological products were a suspect in 54% of all serious and fatal adverse events in drugs administered directly.

CONCLUSION

Adverse reactions to drug therapy are a significant cause of death and injury in infants and children under 2 years of age. Drugs administered to the mother in the perinatal period constituted a major route of exposure to adverse drug advents. These results underscore the need for additional drug testing in the youngest pediatric patients and for carefully weighing the risks versus benefits of medication.

Comparison between pediatricians and family practitioners in the use of the prokinetic cisapride for gastroesophageal reflux disease in children

OBJECTIVE

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition have recently issued treatment guidelines for the use of cisapride in children. Our hypothesis was that cisapride is misused in the community and is not prescribed according to suggested recommendations. Therefore, the aim of this study was to evaluate the knowledge of pediatricians and family practitioners regarding the prescribing practice and adverse effects of cisapride.

METHODS

A standardized questionnaire was sent to a randomly selected group of pediatricians and family practitioners in Northern Israel. The questionnaire was designed to evaluate the knowledge of the physician regarding the treatment of gastroesophageal reflux disease and the use of cisapride in children (indications, dosages, duration of treatment, limitations in certain age groups, the need for pretreatment laboratory tests, interactions with other drugs, and contraindications). Replies were scored from 0 to 100 according to the treatment guidelines of both the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. In addition, 2 questions dealt with the subjective efficacy of the drug and its adverse events.

RESULTS

The knowledge scores were 62% and 51% in the pediatricians and family practitioners, respectively. Other major findings were as follows: 1) 40% of pediatricians and 65% of family practitioners do not prescribe the recommended dose of cisapride, 2) 6% of pediatricians and 42% of family practitioners prescribe cisapride for infantile colic, 3) only 50% of pediatricians and 22% of family practitioners were aware of possible interactions with macrolides, and 4) only 31% of pediatricians and 54% of family practitioners were aware that cisapride might cause prolongation of the QT interval. Only minor adverse events were reported.

CONCLUSIONS

The knowledge of both pediatricians and family practitioners in the use of cisapride in children is suboptimal. It is essential to improve the education of community physicians to reduce the potential for adverse events arising from the misuse of this prokinetic agent.

QTc interval in infants receiving cisapride

OBJECTIVE

To examine the effect of cisapride on the corrected QT (QTc) interval in infants over a 14-day period.

STUDY DESIGN

A prospective cohort study of infants receiving cisapride (0.8 mg/kg per day). Twelve-lead electrocardiograms were obtained before and 3, 5, 7, and 14 days after cisapride initiation.

RESULTS

Fifty infants completed the study; none had arrhythmias. Fifteen of 50 infants (30%) developed QTc interval > or =450 msec; QTc interval normalized in 13 of 15 infants. Infants with QTc interval on day 3 > or =2 standard deviations above the mean baseline QTc interval (401+40 msec) were more likely to develop prolonged QTc interval (p<0.0001).

CONCLUSION

QTc interval prolongation was noted in 30% of infants. Subsequently, the majority of those infants had QTc interval normalization by day 14 of cisapride therapy. QTc interval 3 days following cisapride initiation may identify infants at risk for transient QTc interval prolongation. With appropriate monitoring, hospitalized infants receiving cisapride may have improved gastrointestinal motility without cardiac morbidity.

Efficacy and tolerability of cisapride in children

As gastro-oesophageal reflux disease (GORD) in infants and children is a motility disorder which differs in pathophysiology and clinical course from GORD in adults, prokinetics should be considered the drug of choice in certain circumstances. Indeed, cisapride may result in improvement of feeding tolerance in premature infants. Cisapride has a better tolerability profile than a 'wait-and-see-if-improvement-comes-spontaneously' policy or the other therapeutic options available. A careful and critical review of published data suggests that cisapride may have a QTc-prolonging effect. However, provided the precautions for cisapride administration are followed, the QTc-prolonging effect remains consistently without clinically relevant adverse effects. Correct dosage and avoidance of concurrent treatment with macrolides and/or azoles are the most relevant tolerability recommendations in children. Although there is a need for a prokinetic with better efficacy, cisapride is currently the prokinetic with the best benefit-to-risk ratio available. Thus, withdrawal of cisapride would result in a significantly increased risk for severe complications in infants and children with GORD or other gastrointestinal motility disorders such as chronic intestinal pseudo-obstruction, gastroparesis and feed intolerance in premature infants.

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.

Cisapride plasma levels and corrected QT interval in infants undergoing routine polysomnography

BACKGROUND

Reported QTc prolongation associated with cardiac arrhythmia in a small number of children undergoing cisapride therapy and lack of pharmacokinetic correlation provided the impetus for this prospective study. The authors evaluated the relation between cisapride plasma concentrations, the electrocardiographic QT interval, and cardiac rhythm in infants undergoing routine 8-hour polysomnography.

METHODS

A total of 211 infants were enrolled: 84 (17 born prematurely) undergoing cisapride therapy for at least 4 days for suspected gastroesophageal reflux and 127 controls (10 born prematurely), aged between 1 week and 13.5 months. Infants underwent continuous bipolar limb lead I recording during routine 8-hour polysomnography. QT intervals and heart rate were measured at hourly intervals. The morning after polysomnography, 12-lead electrocardiography was performed (1 hour after cisapride administration). Cisapride plasma concentrations were determined immediately before and 1 to 2 hours after administration. Serum electrolyte concentrations were measured.

RESULTS

The administered cisapride dose ranged from 0.35 to 1.55 (mean, 0.81, median 0.79) mg. kg-1. d-1. Cisapride plasma concentrations were significantly higher in infants younger than 3 months of age. Cisapride-treated infants younger than 3 months of age had longer QTc intervals compared with age-matched controls. Heart rate was similar for cisapride-treated and control infants. No arrhythmia or atrioventricular conduction abnormalities were observed.

CONCLUSIONS

At comparable doses of cisapride and comparable plasma concentrations, the QTc was significantly higher in infants younger than 3 months of age. This confirms age-dependent cisapride pharmacokinetics in the first 10 to 12 weeks strongly correlated with changes in body weight and may also suggest an altered ability of infants younger than 3 months of age to metabolize cisapride. The clinical significance and risk of the increased QTc interval is unclear. Cisapride should be judiciously prescribed in infants younger than the age of 3 months and electrocardiography should be performed before and during therapy.

Cisapride associated with QTc prolongation in very low birth weight preterm infants

OBJECTIVE

No systematic study has been performed to evaluate the effect of cisapride on the QT interval in premature infants. Cisapride, which has recently been withdrawn by the Food and Drug Administration and is no longer an approved therapy, was commonly used for preterm infant care to improve the advance of enteral feedings and to reduce reflux and associated apnea. Our aim was to evaluate the effect of recommended doses of cisapride on the QT interval in this population.

STUDY DESIGN

Prospective blinded evaluation of electrocardiogram for QT, JT, QTc, and JTc measurements in 25 preterm infants before and after cisapride administration.

RESULTS

Twelve of 25 infants (48%) developed repolarization abnormalities with cisapride administration: 32% of the infants (8/25) studied had QTc prolongation (>/=0.450 seconds), whereas 10/25 had JTc prolongation (>/=0.360 seconds). Preterm infants <32 weeks significantly prolonged their QTc interval from 0.41 +/- 0.02 to 0.44 +/- 0.02. The QTc and/or JTc was prolonged in 54% of infants receiving 0.1 mg/kg/dose and 42% receiving 0.2 mg/kg/dose.

CONCLUSIONS

The QTc and JTc interval significantly prolonged in preterm infants <32 weeks on the recommended dose of cisapride therapy. A QTc >/=0.450 seconds developed in 32% of infants treated with cisapride, whereas the JTc prolonged in 40%. A significant percentage of infants (54%) developed prolonged QTc intervals at a dose of 0.1 mg/kg/dose. From these data we conclude that there is a higher risk of prolongation of the QTc interval and risk of arrhythmias with greater prematurity.

Effectiveness and safety of a protocol for promotion of early intragastric feeding in critically ill children

OBJECTIVES: To investigate the feasibility, adequacy, and efficacy of early poststress intragastric feeding (EPIGF) in critically ill children. DESIGN: A prospective clinical study. SETTING: Pediatric intensive care unit in a tertiary care children's hospital. PATIENTS: Seventy-one consecutively enrolled critically ill children requiring prolonged mechanical ventilation. INTERVENTIONS: Full-strength intragastric tube feedings (Nutrison Pediatric, Standard) were initiated within 12 hrs of the study-entry event. Enteral feedings were advanced to a target volume of energy intake = 1/2, 1, 5/4, 6/4, and 6/4 of the predicted basal metabolic rate (PBMR) on days 1-5, respectively. MEASUREMENTS AND MAIN RESULTS: Nutritional status by the caloric intake, recommended dietary allowances, PBMR, predicted energy expenditure (PEE), anthropometry, and clinical indices were evaluated on days 1 and 5. Safety was assessed by the clinical course of disease, laboratory findings, and occurrence of complications. Success was determined by accomplishment of the PEE target. The early success rate was 94.4% and predicted late enteral feeding success accurately (p =.0001). Caloric intake approached PBMR the second day (43 +/- 1.7 kcal/kg/day vs. 43.2 +/- 1.1 kcal/kg/day) and PEE the fifth day (66.2 +/- 2.7 kcal/kg/day vs. 67.7 +/- 6.4 kcal/kg/day). Multivariate stepwise regression analysis showed that poor outcome and a high Therapeutic Intervention Scoring System score correlated with failure of EPIGF (p <.0001). Patients who succeeded EPIGF had significantly higher myocardial ejection (65% vs. 43%; p <.0001) or shortening fractions (34% vs. 20%; p =.0001) on day 1 than those who failed. Patients tolerated EPIGF well; 9.9% developed nosocomial pneumonia, 5.6% developed diarrhea, and 8.5% needed treatment with cisapride because of a delay of gastric emptying. The mortality rate (5.6%) was different between initial and final success and failure groups (p <.0001) and was lower than predicted by the admission severity scores (12% +/- 2%). CONCLUSIONS: This study showed that increases of caloric intake during the acute phase of a critical illness are well tolerated and may approach PBMR by the second day and PEE by the fourth day in critically ill children. Caloric intake lower than PBMR is associated with higher mortality and morbidity rates.

Does cisapride influence cardiac rhythm? Results of a United States multicenter, double-blind, placebo-controlled pediatric study

BACKGROUND

Major concerns about serious cardiac side effects underlie the recent decision by the FDA and Janssen Pharmaceutica (Titusville, NJ) to make cisapride available only through a limited access program. Concerns have grown despite the fact that most instances of prolonged QTc and other ventricular arrhythmias occurred while the drug was used concomitantly with contraindicated drugs. This study sought to analyze electrocardiograms (ECGs) from a multicenter pediatric study and to identify abnormalities in QTc interval associated with cisapride use.

METHODS

Children between 6 months and 4 years of age were enrolled if they manifested symptoms of gastroesophageal reflux not responding to medical therapy for at least 6 weeks. In 49 subjects, ECGs obtained before and after randomization to receive 0.2 mg/kg dose three times daily or placebo were reviewed independently and blindly by two pediatric cardiologists. Placebo and active drug groups were compared for QTc and for change in QTc from baseline values after 3 to 8 weeks of treatment.

RESULTS

Mean QTc among patients taking the drug was 408+/-18 ms. None was higher than 450 ms. Change between baseline and subsequent QTc at 3 to 8 weeks of treatment was 2+/-20 ms.

CONCLUSIONS

In our study group of children without underlying cardiac disease or electrolyte imbalance, cisapride was found to have no significant effect on cardiac electrical function compared with placebo. These results are consistent with the drug's record of exceedingly infrequent cardiac events. Because the availability of this prokinetic is threatened, its safety and the safety and efficacy of alternative treatment options (including surgery) should be studied further.

Effects of cisapride on corrected QT interval, heart rate, and rhythm in infants undergoing polysomnography

OBJECTIVE

To evaluate the effects of cisapride, a prokinetic gastrointestinal drug, on the electrocardiographic QT interval, heart rate, and rhythm in infants during routine 8-hour polysomnography. Reported electrocardiogram (ECG) and rhythm disturbances in a small number of patients with the use of cisapride provided the impetus for this prospective study.

STUDY DESIGN

Two hundred fifty-two infants born at term were enrolled. Of these, 134 were on cisapride therapy for suspected gastroesophageal reflux and 118 were not on cisapride and served as controls. Cisapride-treated and control infants were from the outset divided into 3 age groups; group 1: under 3 months of age; group 2: between 3 and 6 months of age; and group 3: >6 months of age. Continuous ECG bipolar limb lead I recording, saturation monitoring, and electroencephalography were conducted. QT intervals and heart rate were measured at hourly intervals.

RESULTS

Cisapride doses were: group 1 mean, 0.80 mg/kg/day (range: 0.38-1.55); group 2 mean, 0.80 mg/kg/day (range: 0. 23-1.38); and group 3 mean, 0.72 mg/kg/day (range: 0.32-1.41). Heart rate was higher in the younger infants, with a gradual decrease with age. No difference in heart rate was detected between the cisapride and control groups. The QTc interval in patients in group 1 was statistically longer than the controls, when applying both Bazett's and Hodges' formulae for QT correction. The other age groups did not differ. No arrhythmia or atrioventricular conduction abnormalities were observed.

CONCLUSION

Infants under 3 months of age on cisapride treatment had significantly longer QTc intervals (with Bazett's formula, the 98th percentile was 504 ms in the cisapride group vs 447 ms in controls). The clinical significance and risk of the increased QTc interval in these infants are unclear and need further evaluation and risk stratification. Meanwhile, cisapride should be judiciously prescribed in infants <3 months of age.

Cisapride and QTc interval in children

BACKGROUND

Recent reports about cisapride have raised some concerns about the safety and efficacy of this medication in children. The aim of this study was to identify electrocardiographic changes and a predisposition to develop arrhythmias in children.

METHODS

Patients were divided in 2 groups: 1) 63 children (mean age: 29 months) who received cisapride (0.2 mg/kg/dose 3 times/day), and 2) 57 children (mean age: 27 months) who did not receive cisapride (they served as controls). Both groups did not have any associated disease. Electrocardiogram (EKG) was performed to children when they were included in the study. The QT interval was corrected using Bazett's formula. Twenty-four-hour Holter recording was performed in children with prolonged QT interval (PQTI). When PQTI was identified in group 1, cisapride was discontinued and a new EKG was performed.

RESULTS

Five children from group 1 and 6 from group 2 had PQTI. In 3 children with PQTI, the QTc interval returned to normal values when cisapride was discontinued. In children under 4 months of age, a statistical difference was found, with QTc interval being longer in group 2 (without cisapride) than in group 1. Holter recordings were normal in all children with PQTI.

CONCLUSION

PQTI can be found in normal children with or without cisapride. In our study PQTI was not associated with any life-threatening event.

Role of drug therapy in the treatment of gastro-oesophageal reflux disorder in children

Gastro-oesophageal reflux (GOR) is the effortless passage of gastric contents into the distal oesophagus. It can be classified as functional (or symptomatic), in which the infant remains free from disease, or a pathological (GOR disease, GORD), in which gastrointestinal, respiratory or neurobehavioural signs occur with intraoesophageal acidification and the development of oesophagitis. Functional or symptomatic GOR is successfully treated by conservative measures and does not require investigative diagnostic tools; however, both drug administration and an investigative approach are mandatory in patients with GORD. There is currently a great range of proven therapeutic options for GORD that are directed at counteracting the pathogenetic components of the disorder. In this report we discuss the role of different drug classes for treating GORD in children. The choice of therapy for GORD depends upon the severity of signs and the degree of oesophagitis. The presence of oesophagitis, as documented by endoscopy, suggests the use of antisecretory drugs; H2 receptor antagonists are the first-line agents. Nevertheless, individuals with refractory disease or those patients requiring potent inhibition of acid secretion (for example, GORD with respiratory involvement) can be given proton pump inhibitors. Other groups of patients who need potent inhibition of acid secretion are children with neurological dysfunction and those with Barrett's oesophagus. It is still unclear whether patients with frequent relapses are candidates for long term administration of antisecretory drugs or for surgical fundoplication.

Advances in the management of pediatric constipation

Constipation in children is a common concern. There is no single treatment; many children do not respond and continue to have chronic problems. This lack of response is multifactorial, but it is most likely related to the fact that the exact pathophysiology of constipation in children is not known. Diagnostic criteria (Rome II classification) and algorithms proposed by the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) for evaluation and treatment of children with constipation were recently published and are summarized here. The effectiveness of new treatments such as dietary interventions, prokinetic agents, biofeedback, and polyethylene-glycol electrolyte (PEG) solutions is discussed in this review.

Medical management of gastroesophageal reflux

Gastroesophageal reflux (GER) is a common problem which can manifest as vomiting, failure to thrive, recurrent pneumonias, asthma, sinusitus, or subglottic stenosis. The medical management plan should be individualized. A "happy spitter" who has no complications of GER may respond well to conservative management, including positioning and thickening of feedings. A child with complications may require treatment with H-2 antagonists or proton pump inhibitors in conjunction with prokinetic agents. Children with gastrointestinal symptoms suggestive of GER who do not respond to antireflux management may need to be treated for eosinophilic esophagitis. Recent studies that assess the effect of medications on recognized complications of GER are reviewed.

Effect of cisapride on the QT interval in infants with gastroesophageal reflux

OBJECTIVE

We prospectively studied the effect of cisapride per se on QT interval in young infants (3-6 months) with gastroesophageal reflux (GER) in a controlled setting.

STUDY DESIGN

The infants diagnosed with GER and deemed to require therapy with cisapride were divided into 2 groups. Group A comprised infants with GER who underwent an electrocardiogram (ECG) before initiation of therapy with cisapride in the dose of 1 mg per kg per 24 hours, divided into 3 doses. They were reweighed after 7 to 10 days, and the dose was adjusted for their new weight. A repeat ECG was performed after approximately 2 weeks (12-18 days) of therapy. The QT interval was measured in each ECG and then the corrected QT interval was calculated by Bazett's formula. Group B comprised infants with GER who had already been on therapy with cisapride for over 1 month. All infants in group B received cisapride in an approximate dose of 1 mg per kg per 24 hours (.8-1.1 mg/kg/24 hours) given in 3 divided doses. They underwent only 1 ECG, ie, at 1 to 4 months after initiation of therapy. The measurement of the actual dose of cisapride was demonstrated to every parent and a marked measuring syringe was provided. The following categories of infants were not included: those with any underlying cardiopulmonary, renal, or hepatic problem; those with a history of apnea; those using a macrolide antibiotic or azole antifungal at any stage during the study; and infants hospitalized for any reason during the course of the study.

RESULTS

Cisapride therapy in the dose of 1 mg/kg/day frequently resulted in a slight increase in the QT interval (pretreatment: 390 +/- 18 milliseconds; posttreatment: 400 +/- 20 milliseconds) but the increase was still below the accepted upper limit of 440 milliseconds and not statistically significant. Even with prolonged therapy, the pattern of change in QT interval was similar to that with therapy for 2 weeks. Overall, 2 of 100 (2%) infants developed a prolongation of corrected QT interval beyond the normal range (456 and 486 milliseconds). Neither infant had evidence of any arrhythmia or conduction defect on ECG. No additional factor could be identified in either infant to explain prolongation of the QT interval.

CONCLUSION

Our experience suggests that cautious cisapride therapy in young infants in a modest dose does not result in arrhythmias or conduction defects. We recommend that: 1) the dose of cisapride in infants be <1.2 mg/kg/day and preferably between.8 and 1 mg/kg/day; 2) the right measure of the dose be actually demonstrated to the parents; and 3) parents be provided a list of drug interactions with cisapride. One should think twice before denying the use of an effective drug simply because of the need for closer monitoring and extra time spent for parent education.

Cisapride for the treatment of constipation in children: A double-blind study

OBJECTIVE

To determine whether cisapride is effective in the treatment of children with constipation.

STUDY DESIGN

Double-blind, placebo-controlled study in which children with chronic constipation were randomly assigned to treatment with cisapride or placebo for 12 weeks.

RESULTS

Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 (76%) subjects in the cisapride group and 8 of 19 (37%) subjects in the placebo group (P <.03). The odds ratio for response after cisapride administration was 8.2 times higher (95% CI 1.3 to 49.4). During cisapride therapy, there was a significant improvement in number of spontaneous bowel movements per week (from 0.9 +/- 0.1 to 4.1 +/- 1.1), and there was a significant decrease in number of fecal soiling episodes per day (1.8 +/- 0.5 to 0.08 +/- 0.4), percent with encopresis (82% vs 23%), number of laxative doses per week (from 10.3 +/- 2.6 to 0.8 +/- 0.6), percent using laxatives (77% to 24%), and total gastrointestinal transit time (from 115.0 +/- 3.7 hours to 77.0 +/- 11.1 hours). With placebo, there were no significant changes in the number of spontaneous bowel movements (from 1.0 +/- 0.8 to 2.2 +/- 0.6), percent with encopresis (74% vs 47%), or total gastrointestinal transit time (from 112.5 +/- 4.9 hours to 95.4 +/- 9.8 hours); but there was a significant decrease in number of fecal soiling episodes per day (from 1.3 +/- 0.4 to 0.4 +/- 0.2) and number of laxative doses used per week (from 11.5 +/- 2.9 to 2.05 +/- 0.7). The final number of spontaneous bowel movements, fecal soiling episodes, laxatives used, or percent patients with encopresis was not different when patients receiving cisapride were compared with those receiving placebo.

CONCLUSION

Cisapride was effective in the treatment of children with constipation.

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition

BACKGROUND

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers.

METHODS

The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and 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.

RESULTS

The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist.

CONCLUSIONS

This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.