Gastro-oesophageal reflux is the movement of stomach contents back into the oesophagus. A ring of smooth muscle (sphincter) at the lower end of the oesophagus near the stomach usually prevents this regurgitation. Relaxation of the sphincter, ineffective clearance of food from the oesophagus into the stomach, and delayed emptying of the stomach can all contribute to reflux. The peak incidence of reflux is generally at around four months of age and resolves by one to two years. Parents may seek medical help for the reflux if they are anxious or find the symptoms of regurgitation, crying, irritability, vomiting and, gagging difficult to tolerate. Some young children experience associated respiratory problems of chronic cough, wheezing, hoarseness, recurring bronchitis, pneumonia, apnoea or breath holding; and back-arching, refusal to feed and sleep disturbance. Inflammation of the oesophagus may be evident with endoscopy or the child may fail to thrive and surgery may be required. Scintigraphy or sonography are used to monitor oesophageal motility.
Attention to the child’s position (by avoiding lying flat or a slumped seated position) and diet (thickened feeds, frequent small meals, non-prescription stabilisers such as Gaviscon) may be effective in reducing reflux. Medications include prokinetic drugs given before a meal to stimulate gut motility and acid-secretion inhibitors. Cisapride is a prokinetic drug used to improve symptoms and avoid serious complications of reflux. From this systematic review, we found no clear evidence of reduced symptoms of reflux with cisapride compared to placebo or no treatment. The parent or guardian of the child or the treating physician assessed the symptoms (regurgitation, crying, irritability, vomiting, gagging) at the end of treatment. Nine trials compared cisapride with placebo or no treatment, of which eight (262 participants) reported data on symptoms of gastro-oesophageal reflux in children aged between five days and five years. They were followed up for two weeks to eight weeks.
Investigations of reflux can include oesophageal pH monitoring for 18 to 24 hours to determine the number of episodes of pH < 4, duration of the longest episode of pH < 4 and the presence of sleep reflux. These pH measurements poorly correlate with symptoms and responses of a child to treatment.
Cisapride significantly reduced the percentage of time the pH < 4 (reflux index) but not other measures of oesophageal pH monitoring
Fatal cardiac arrhythmia or sudden death have been associated with cisapride use in children and it is only used within restricted programmes under specialist supervision. One multicentre study of 134 children found no electrocardiographic QTc interval changes with cisapride.