Randomised controlled trial of cisapride in preterm infants

Update on pediatric gastroparesis: A review of the published literature and recommendations for future research

BACKGROUND

Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis.

METHODS

A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility.

KEY RESULTS

Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data.

CONCLUSIONS

Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.

Childhood gastroparesis is a unique entity in need of further investigation

BACKGROUND

Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures.

PURPOSE

The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.

Pharmacologic Treatment for Pediatric Gastroparesis: A Review of the Literature

There have been a number of agents that have been tried for treatment of gastroparesis over the past 3 decades, with varying levels of success. Guidelines exist for the management of gastroparesis in adults; however, even though the cause of gastroparesis in children is similar to that in adults, no guidelines exist for treating pediatric gastroparesis as studies on the topic are limited. With what little information we have on pediatric gastroparesis, medications used in children's studies do not seem to demonstrate the same results as in adult patients with gastroparesis; thus, future studies of whether certain medications are effective for treating pediatric gastroparesis and at what dose still need to be conducted. Pharmacological treatment options for pediatric gastroparesis do not show a clear correlation of resolving or even maintaining gastroparesis-associated symptoms or disease state. This article reviews the available studies of drugs that have shown some efficacy, with an emphasis on pediatric studies.

Body positioning and medical therapy for infantile gastroesophageal reflux symptoms

OBJECTIVE

Proton-pump inhibitors (PPIs) reduce acid gastroesophageal reflux (GER) and esophageal acid exposure in infants; however, they do not reduce total GER or symptoms attributed to GER. Reflux is reduced in the left lateral position (LLP). We hypothesize that the effect of LLP in combination with acid suppression is most effective in reducing GER symptoms in infants.

METHODS

In this prospective sham-controlled trial, infants (0-6 months) with symptoms suggestive of gastroesophageal reflux disease were studied using 8-hour pH-impedance, cardiorespiratory and video monitoring, direct nurse observation, and a validated questionnaire. Infants demonstrating a positive GER symptom association were randomized to 1 of 4 groups; PPI + LLP, PPI + head of cot elevation (HE), antacid (AA) + LLP, or AA + HE. HE and AA were considered "sham" therapies. After 2 weeks the 8-hour studies were repeated on-therapy.

RESULTS

Fifty-one patients were included (aged 13.6 [2-26] weeks). PPI + LLP was most effective in reducing GER episodes (69 [13] to 46 [10], P < 0.001) and esophageal acid exposure (median [interquartile range] 8.9% [3.1%-18.1%] to 1.1% [0%-4.4%], P = 0.02). No treatment group showed improvement in crying/irritability, although vomiting was reduced in AA + LLP (from 7 [2] to 2 [0] episodes P = 0.042). LLP compared with HE produced greater reduction in total GER (-21 [4] vs -10 [4], P = 0.056), regardless of acid-suppressive therapy. Acid exposure was reduced on PPI compared with AA (-6.8 [2.1] vs -0.9 [1.4]%, pH < 4, P = 0.043) regardless of positional intervention. A post-hoc analysis using automated analysis software revealed a significant reduction in crying symptoms in the PPI + LLP group (99 [65-103] to 62 [32-96] episodes, P = 0.018).

CONCLUSIONS

"Symptomatic gastroesophageal reflux disease" implies disease causation for distressing infant symptoms. In infants with symptoms attributed to GER, LLP produced a significant reduction in total GER, but did not result in a significant improvement in symptoms other than vomiting; however, automated analysis appeared to identify infants with GER-associated crying symptoms who responded to positioning therapy. This is an important new insight for future research.

Pharmacological therapy of gastroesophageal reflux in preterm infants

Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.

Systematic review: cardiovascular safety profile of 5-HT(4) agonists developed for gastrointestinal disorders

BACKGROUND

The nonselective 5-HT(4) receptor agonists, cisapride and tegaserod have been associated with cardiovascular adverse events (AEs).

AIM

To perform a systematic review of the safety profile, particularly cardiovascular, of 5-HT(4) agonists developed for gastrointestinal disorders, and a nonsystematic summary of their pharmacology and clinical efficacy.

METHODS

Articles reporting data on cisapride, clebopride, prucalopride, mosapride, renzapride, tegaserod, TD-5108 (velusetrag) and ATI-7505 (naronapride) were identified through a systematic search of the Cochrane Library, Medline, Embase and Toxfile. Abstracts from UEGW 2006-2008 and DDW 2008-2010 were searched for these drug names, and pharmaceutical companies approached to provide unpublished data.

RESULTS

Retrieved articles on pharmacokinetics, human pharmacodynamics and clinical data with these 5-HT(4) agonists, are reviewed and summarised nonsystematically. Articles relating to cardiac safety and tolerability of these agents, including any relevant case reports, are reported systematically. Two nonselective 5-HT(4) agonists had reports of cardiovascular AEs: cisapride (QT prolongation) and tegaserod (ischaemia). Interactions with, respectively, the hERG cardiac potassium channel and 5-HT(1) receptor subtypes have been suggested to account for these effects. No cardiovascular safety concerns were reported for the newer, selective 5-HT(4) agonists prucalopride, velusetrag, naronapride, or for nonselective 5-HT(4) agonists with no hERG or 5-HT(1) affinity (renzapride, clebopride, mosapride).

CONCLUSIONS

5-HT(4) agonists for GI disorders differ in chemical structure and selectivity for 5-HT(4) receptors. Selectivity for 5-HT(4) over non-5-HT(4) receptors may influence the agent's safety and overall risk-benefit profile. Based on available evidence, highly selective 5-HT(4) agonists may offer improved safety to treat patients with impaired GI motility.

Cisapride: what can we learn from the rise and fall of a prokinetic?

Cisapride, the prototype serotonergic agent, evolved from a body of research that defined the key roles of serotonergic receptors in gastrointestinal motor and sensory function. Impressed by its in vitro properties and encouraged by clinical trial data, cisapride became the drug of choice for the treatment of a wide range of motility disorders and clinicians appeared impressed by its efficacy and comfortable with its side-effect profile. Once serious cardiac events began to be reported in association with cisapride therapy, dark clouds rapidly gathered and soon enveloped the drug, leading to its widespread withdrawal from markets. What lessons can we learn from the story of cisapride? How can its brief but spectacular rise and equally sensational demise inform the development of new drugs which are so sorely needed in the management of motility and functional gastrointestinal disorders? This review explores the background to the development of cisapride, its history in clinical trials and the experience with adverse events and, in so doing, attempts to identify lessons for the future in the therapeutics of enteric neuromodulatory drugs.

Cisapride treatment for gastro-oesophageal reflux in children

BACKGROUND

Gastro-oesophageal reflux (GOR) is common and usually self-limiting in infants. Cisapride, a pro-kinetic agent, was commonly prescribed until reports of possible serious adverse events were associated with its use.

OBJECTIVES

To determine the effectiveness of cisapride versus placebo or non-surgical treatments for symptoms of GOR.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Specialised Register and Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, reference lists of relevant review articles and searched in the Science Citation Index for all the trials identified. All searches were updated in February 2009.

SELECTION CRITERIA

Randomised controlled trials comparing oral cisapride therapy with placebo or other non-surgical treatments for children diagnosed with GOR were included. We excluded trials with a majority of participants less than 28 days of age.

DATA COLLECTION AND ANALYSIS

Primary outcomes were a change in symptoms at the end of treatment, presence of adverse events, occurrence of clinical complications and weight gain. Secondary outcomes included physiological measures of GOR or histological evidence of oesophagitis. We dichotomised symptoms into 'same or worse' versus 'improved' and calculated summary odds ratios (OR). Continuous measures of GOR (for example reflux index) were summarised as a weighted mean difference. All outcomes were analysed using a random-effects method.

MAIN RESULTS

Ten trials in total met the inclusion criteria. Nine trials compared cisapride with placebo or no treatment, of which eight (262 participants) reported data on symptoms of gastro-oesophageal reflux. There was no statistically significant difference between the two interventions (OR 0.34; 95% CI 0.10 to 1.19) for 'same or worse' versus 'improved symptoms' at the end of treatment. There was significant heterogeneity between the studies, suggesting publication bias. Four studies reported adverse events (mainly diarrhoea); this difference was not statistically significant (OR 1.80; 95% CI 0.87 to 3.70). Another trial found no difference in the electrocardiographic QTc interval after three to eight weeks of treatment. Cisapride significantly reduced the reflux index (weighted mean difference -6.49; 95% CI -10.13 to -2.85; P = 0.0005). Other measures of oesophageal pH monitoring did not reach significance. One included study compared cisapride with Gaviscon (with no statistically significant difference). One small study found no evidence of benefit on frequency of regurgitation or weight gain after treatment with cisapride versus no treatment, carob bean or corn syrup thickeners.

AUTHORS' CONCLUSIONS

We found no clear evidence that cisapride reduces symptoms of GOR. Due to reports of fatal cardiac arrhythmias or sudden death, from July 2000 in the USA and Europe cisapride was restricted to a limited access programme supervised by a paediatric gastrologist.

High-dose oral erythromycin decreased the incidence of parenteral nutrition-associated cholestasis in preterm infants

BACKGROUND & AIMS

Feeding intolerance because of functional gastrointestinal dysmotility and parenteral nutrition-associated cholestasis (PNAC) are common problems in preterm, very-low-birth-weight (VLBW) infants. This double-blind, randomized, placebo-controlled study aimed to assess the effectiveness of "high-dose" oral erythromycin as a prokinetic agent in decreasing the incidence of PNAC. Two secondary end points, including the time to achieve full enteral feeding and the duration of parenteral nutrition, were also evaluated.

METHODS

Infants consecutively admitted to the neonatal unit were randomized to receive erythromycin (12.5 mg/kg/dose every 6 hours for 14 days) or an equivalent volume of normal saline (placebo) if they attained less than half the total daily fluid intake (<75 mL/kg/day) as milk feeds on day 14 of life.

RESULTS

Of 182 VLBW infants enrolled, 91 received erythromycin. The incidence of PNAC was significantly lower in erythromycin-treated infants (18/91) compared with placebo infants (37/91; P = .003). Treated infants achieved full enteral nutrition significantly earlier (mean, 10.1; SE, 1.7 days; P < .001), and the duration of parenteral nutrition was also significantly decreased by 10 days (P < .001). Importantly, fewer infants receiving erythromycin had 2 or more episodes of septicemia (n = 4) compared with placebo patients (n = 13, P = .03). No serious adverse effect was associated with erythromycin treatment.

CONCLUSIONS

High-dose oral erythromycin can be considered as a rescue measure for VLBW infants who fail to establish adequate enteral nutrition and in whom anatomically obstructive pathologies of the gastrointestinal tract have been excluded.

Cisapride treatment for gastro-oesophageal reflux in children

BACKGROUND

Gastro-oesophageal reflux (GOR) is an extremely common and usually self-limiting condition in infants. When treatment is required, Cisapride, a pro-kinetic agent, has been commonly prescribed for the symptomatic management of GOR. There have been recent reports of possibly serious adverse events, e.g. an increased QTc interval, cardiac arrhythmias, and death, associated with the use of Cisapride.

OBJECTIVES

To determine the effectiveness of Cisapride for symptoms of GOR compared with placebo or any other non-surgical treatments.

SEARCH STRATEGY

Searches were conducted of the Cochrane Central Trials Register and the specialised Trials register of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group, MEDLINE and Embase up till April 2002. Reference lists of relevant review articles and identified trials were scrutinised and forward citation searches were performed in the Science Citation Index on all trials identified. The search was re-run in August 2003 and no new trials were found.

SELECTION CRITERIA

Randomised controlled trials that compared oral Cisapride therapy with placebo or with other non-surgical treatments for children with a diagnosis of GOR were included. Only studies in which Cisapride was administered orally for a minimum of one week and which documented at least one of the primary outcomes were included. We excluded trials in which the majority of participants were aged less than 28 days.

DATA COLLECTION AND ANALYSIS

The primary outcomes were defined as a change in symptoms at the end of treatment, presence of adverse events, occurrence of clinical complications, and weight gain. The secondary outcomes included physiological measures of GOR or histological evidence of oesophagitis. We dichotomised symptoms into 'same or worse' vs 'improved' and calculated summary odds ratios. Continuous measures of GOR (e.g. reflux index) were summarised as a weighted mean difference. All outcomes were analysed using a random effects method.

MAIN RESULTS

Searches identified nine trials which met the inclusion criteria. Eight trials compared Cisapride with placebo, of which seven (236 participants) reported data on symptoms of gastro-oesophageal reflux, and one reported data on the QTc interval (49 patients). The odds ratio for 'same or worse' vs 'improved symptoms' at the end of treatment of 0.34 (95%CI 0.10, 1.19) did not show a statistically significant difference between the two interventions. There was significant heterogeneity between the studies and the funnel plot suggested publication bias. In a sensitivity analysis, the definition of outcomes was changed to 'any symptoms' vs 'no symptoms'. This resulted in the exclusion of three trials (one of them the largest, best quality trial). The resulting pooled odds ratio showed a significant effect of Cisapride (OR 0.19, 95%CI 0.08, 0.44). Five studies reported adverse events. Four reported adverse events (mainly diarrhoea) but the difference was not statistically significant (OR 1.80, 95%CI 0.87, 3.70). One trial found no difference in the QTc after 3 to 8 weeks of treatment. Cisapride was associated with a statistically significant reduction in the reflux index (weighted mean difference -6.49, 95%CI -10.13, -2.85), but as reflux index and clinical symptoms are poorly correlated, the clinical importance of this finding is uncertain. Other measures of oesophageal pH monitoring did not reach significance. One included study compared Cisapride with Gaviscon (or Gaviscon and Carobel). The odds ratio for 'same or worse' vs 'improvement' in the Cisapride group compared with Gaviscon was 3.26 (95%CI 0.93-11.38).

REVIEWER'S CONCLUSIONS

We found no clear evidence that Cisapride reduces symptoms of GOR. The results suggested substantial publication bias favouring studies showing a positive effect of Cisapride. This finding is supported by the report of one unpublished multi-centre study of 134 patients, which was reported to show no evidence of a significant effect of Cisapride. Due to reports of fatal cardiac arrhythmias or sudden death, from July Due to reports of fatal cardiac arrhythmias or sudden death, from July 2000, cisapride was restricted to a limited access programme supervised by a paediatric gastrologist in the USA and in Europe, to patients treated within a clinical trial or safety study or registry programme.

Mechanisms of gastro-oesophageal reflux in preterm and term infants with reflux disease

BACKGROUND

Transient lower oesophageal sphincter relaxation (TLOSR) is the predominant mechanism of gastro-oesophageal reflux (GOR) in healthy infants but the mechanisms of GOR in infants with GOR disease (GORD) are poorly understood.

AIMS

To measure the occurrence of TLOSR, GOR, and gastric emptying (GE) rate in preterm and term infants with GORD.

PATIENTS

Thirty six infants were studied and grouped as normals or GORD based on a routine clinical assessment and confirmation of an assessment of GORD by reflux symptom charts and oesophageal pH monitoring.

METHODS

A micromanometric assembly incorporating a micro pH electrode recorded oesophageal motility and pH. GE rate was determined using the (13)C-octanoic acid breath test.

RESULTS

TLOSR was the predominant mechanism of GOR, triggering 50-100% of GOR episodes (median 91.5%). Abdominothoracic straining significantly increased the occurrence of GOR in association with TLOSR. In infants with GORD, the number of TLOSRs overall was similar to normals but the proportion of TLOSRs accompanied by acid GOR was significantly higher than in normals (16.5% v 5.7%, respectively; p<0.001). Infants with GORD had a similar GE rate to normals.

CONCLUSIONS

In infant GORD, acid reflux associated TLOSRs are abnormally common and likely to be a major contributing factor to the pathophysiology of GORD. Infants with GORD do not have delayed GE.

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.

Apnea at discharge and gastro-esophageal reflux in the preterm infant

OBJECTIVE

To determine the relationship between respiratory patterns and acid gastro-esophageal reflux (g-e reflux) prior to discharge of the formerly preterm infant.

STUDY DESIGN

Forty-five infants of <32 weeks' gestation were studied at an average postmenstrual age of 37.2 weeks (SD 3.5). Following informed parental consent, a 12-hour multichannel recording including esophageal pH was obtained. Apneas of greater than 10 seconds were recorded, as well as the occurrence of bradycardia or desaturation.

RESULTS

Acid g-e reflux (pH <4.0) occurred at least once in all of the infants; prevalence was between <1% and 41% of the 12-hour record (median 4.6%, interquartile range 0.5% to 9%). The number of reflux episodes ranged from 1 to 143 (median 23). The number of apneas (>10 seconds duration) ranged from 0 to 71, median 6. There was no correlation between apnea frequency or severity and reflux frequency or duration. There was no difference in apnea frequencies between the 5 minutes after the start of a reflux episode and the 5 minutes prior to each episode.

CONCLUSION

Acid g-e reflux in the formerly preterm infant at discharge is frequent and may be prolonged; there is no association between reflux and apnea.

Feeding methods for the preterm infant

As more very immature preterm infants survive, provision of enteral feedings has become a major focus of concern. Although many aspects of gastrointestinal function are immature in the preterm infant, the ability of the preterm neonate to process and absorb enteral nutrients appears to be adequate enough to sustain nutritional needs. Few prospective randomized trials have compared the efficacy of different feeding methods. However, some studies have compared differing routes of feeding, rates of feeding, and volume of feeding. The ability to successfully digest enteral feedings may be inhibited or enhanced by pharmacological agents. The need to modify a feeding strategy can be monitored by tracking several measurements prospectively. Finally, there is a need to assess ongoing dietary needs of preterm infants for discharge planning.

The effect of cisapride on the corrected QT interval and QT dispersion in premature infants

BACKGROUND

Cisapride is used frequently in premature neonates as a gastrointestinal prokinetic drug. Concerns exist, however, about its safety because of its effect on the QT interval. Premature infants could be at higher risk for side effects because of their immaturity. This prospective study investigated the pharmacokinetics of cisapride and its effects on corrected QT interval (QTc) and QT dispersion in premature infants.

METHODS

Electrocardiogram examination was performed just before and after 72 hours of treatment with cisapride (0.2 mg/kg per dose, four times daily) in 10 premature infants. Trough and anticipated peak plasma level of cisapride and norcisapride were quantified after 72 hours of treatment. Results were compared with a cohort of 41 term infants aged 0 to 3 months receiving cisapride treatment.

RESULTS

The QTc interval increased significantly from 423 ms to 461 ms after 72 hours of treatment (P = 0.0007). No effect was seen on QT dispersion (44.3 ms vs. 45.9 ms). The change in QTc interval was inversely related to postnatal age (R2 = 0.52; P = 0.02), whereas there was no correlation with gestational age or plasma levels of cisapride or norcisapride. Trough and anticipated peak plasma levels of cisapride and norcisapride were significantly higher in the premature infants compared with the term infants aged 0 to 3 months (P < 0.001).

CONCLUSIONS

Premature infants less than 1 month of age could be at higher risk for cardiac side effects of cisapride when used in the same dosage as in older infants. The daily dose should be reduced (0.1 mg/kg per dose, maximum four times daily), and the QTc interval should be monitored closely. The benefits and safety of cisapride in premature infants less than 1 month of age should be reconsidered.

Gastroesophageal reflux medications in the treatment of apnea in premature infants

OBJECTIVE

To determine whether medications commonly used in the management of gastroesophageal reflux reduce the frequency of apnea in premature infants.

STUDY DESIGN

We reviewed the medical records of all infants </=36 weeks' gestational age at birth who were treated in 2 neonatal intensive care units from 1990 through 1999 and identified those who received the antireflux medications cisapride or metoclopramide in association with apnea. We averaged the frequency of apnea during the 5 days before and the 5 days after antireflux treatment was started and compared these 2 periods by paired analysis.

RESULTS

There were 164 separate courses of treatment with either cisapride or metoclopramide in 132 patients. There were 3.6 +/- 3.2 apneic episodes per day during the 5 days before treatment and 4.0 +/- 3.4 apneic episodes per day during the 5 days after treatment (P =.048). When evaluated separately, neither cisapride nor metoclopramide reduced the frequency of apnea. Stratification for documented reflux (by radiographic contrast or by pH probe analysis), concomitant use of methylxanthines or ranitidine, developmental age, feeding volume, and respiratory support did not identify a subgroup of patients whose apnea improved with antireflux treatment.

CONCLUSION

Antireflux medications do not reduce the frequency of apnea in premature infants.

Improved use of the [13C]octanoic acid breath test as intra-individual parameter to study the effect of a prokinetic drug on gastric emptying in preterm infants with oral feeding intolerance

The [13C]octanoic acid breath test was used for the measurement of differences in gastric emptying in preterm infants for the evaluation of pharmacological therapy. In order to perform a good intra-individual comparison of the gastric emptying in preterm infants under non-standardisable test conditions, we adjusted t1/2 for variations in non-recovered label (=label retention) and introduced an "effective half 13CO2 breath excretion time" t1/2eff = t1/2/m expressed as min per percentage of the cumulative dose recovered. In a pilot study, we investigated the action of the gastrointestinal prokinetic drug cisapride on gastric emptying in seven premature infants, of whom four suffered from gastric stasis and three had constipation. The postnatal age and weight at the start of treatment ranged from 15 to 64 days and from 815 to 1635 g, respectively. All infants received the standard formula for premature infants (Nenatal, Nutricia). Cisapride was administered orally 0.2 mg/kg, four times daily. The changes in gastrointestinal motility were studied using the total bowel transit time of carmine red. After 7 days of treatment in all children, the gastric emptying coefficient and the half 13CO2 breath excretion time adjusted for label retention were improved (n=7, the gastric emptying coefficient range before treatment was 1.69-3.34 (mean 2.59 +/- 0.80) and after treatment it was 2.79-3.76 (mean 3.28 +/- 0.30); the half 13CO2 breath excretion time adjusted for label retention range before treatment was 3.0-14.7 min/% dose (mean 7.0 +/- 5.0) and after treatment 2.6-4.0 min/% dose (mean 3.1 +/- 0.6). The total bowel transit time was only slightly improved in two patients (n=7, mean total bowel transit time before: 23.7 h compared to mean total bowel transit time after 7 days of treatment: 35.5 h). Side effects during cisapride treatment were not seen. We conclude that in premature infants cisapride is effective in shortening gastric emptying time and reducing gastric stasis; the therapeutic role in constipation has to be further investigated.

Enteral feeding in the preterm infant

In planning enteral feeding in the preterm infant, decisions need to be made regarding the feeding schedule, choice of milk, and the route of administration. Feeds should be commenced within a week after birth beginning with subnutritional quantities. Preterm human milk from the infant's own mother is the milk of choice. When full enteral feeding is established, supplementation with human milk fortifier is recommended. Donor human milk and preterm formula are alternatives. Early establishment of enteral nutrition and maintenance of optimal nutrition during infancy are important as dietary manipulations in preterm infants have potential long-term influences on their health, growth and neurodevelopment.