Diagnosis and treatment of gastroesophageal reflux disease in infants and children

Table 1 Symptoms of GER (-disease)

Usual manifestations	Symptoms possibly related to complications of GER*
Specific manifestations
Regurgitation	Symptoms related to anaemia (iron deficiency anaemia)
Nausea	Haematemesis and melaena
Vomiting	Dysphagia (as a symptom of oesophagitis or due to stricture formation)
	Weight loss and/or failure to thrive
	Epigastric or retrosternal pain
	“Non-cardiac angina-like” chest pain
	Pyrosis or heartburn, pharyngeal burning
	Belching, postprandial fullness
	Irritable oesophagus
	General irritability (infants)
Unusual presentations
GER related to chronic respiratory disease (bronchitis, asthma, laryngitis, pharyngitis, etc.)
Sandifer Sutcliffe syndrome
Rumination
Apnea, apparent life threatening event and sudden infant death syndrome
Associated to congenital and/or central nervous system abnormalities
Intracranial tumors, cerebral palsy, psychomotory retardation

A number of these symptoms may also be caused by other mechanisms.

Table 2 Contraindications and risk factors for use of cisapride

Contraindications to cisapride administ ration in pediatric patients
-Combination with medication also known to prolong the QT interval or potent CYP3A4 inhibitors, such as astemizole, fluconazole,
itraconazole, ketoconazole, miconazole, eythromycin, clarithromycin, troleandomycin, nefazodone, indinavir, ritonavir, josamycin,
diphemanil, terfaridine.
-Use of the above medications by a breast-feeding mother, as secretion i n mother's milk of most of these drugs is unknown.
-Known hypersensitivity to cisapride.
-Known congenital long QT syndrome or known idiopathic QT prolongation.
Precautions for cisapride administration in pediatric patients
-Prematurity (a starting dose of 0.1 mg/kg, 4 times daily may be used, although 0.2 mg/kg is also for prematures the normal dose)
-Hepatic or renal failure (particularly when on chronic dialysis). In these cases, it is recommended to start with 50% of the
recommended dose.
-Uncorrected electrolyte disturbances (hypokalemia, hypomagnesemia, hypocal cemia), as may occur in prematures,
in severe diarrhea, in treatment with potassium-wasting diuretics such as furosemide or acetazolamide.
-History of significant cardiac disease including serious ventricular arrhythmia, second or third degree antrioventricular block, congestive heart failure or ischaemic
heart disease, QT prolongation associated with diabetes mellitus.
-History of sudden infant death in a sibling, and/or history of a “serious ” apparent life threatening event in the infant or a sibling.
-Intracranial abnormalities, such as encephalitis or haemorrhage, grape fruit juice.