Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching

BACKGROUND & AIMS

In patients with clinically suspected rumination, esophageal impedance manometry differentiates episodes of rumination (involuntary straining with intragastric pressure increases) from aerophagia/supragastric belching. Treatment options are limited and focused on behavioral therapy. Baclofen, an agonist of the γ-aminobutyric acid B receptor, increases lower esophageal sphincter pressure and decreases swallowing rate. We investigated its effects in these patients.

METHODS

High-resolution manometry-impedance recordings were taken from 12 patients (8 women; mean age, 45 years; range, 18-89 years) with clinically suspected rumination or supragastric belching before and during treatment with baclofen (10 mg, 3 times daily). After 30 minutes of recordings, patients received a 1000-kcal solid meal; recordings were then continued for 1 hour. Patients were asked to register symptoms with an event marker. The number of symptoms registered and number and type of flow events were compared before and during treatment.

RESULTS

An average of 20 symptom markers (range, 14-34) were recorded at baseline (10 [range, 4-25] for belching and 9 [range, 0-11] for regurgitation). This was significantly reduced to 6 (range, 2-22) (3 [range, 1-15] for belching and 1 [range, 0-13] for regurgitation) during baclofen treatment (P = .01). The number of flow events (473 at baseline [42 reflux, 192 rumination, 188 supragastric belching, and 42 aerophagia]) was significantly reduced to 282 (32 reflux, 99 rumination, 123 supragastric belching, and 13 aerophagia) during baclofen therapy (P = .02). The reduction in flow events correlated with the increase in lower esophageal sphincter pressure (r = -0.62; P = .03) and reduction in swallowing frequency (r = 0.64; P = .02).

CONCLUSIONS

Baclofen is an effective treatment for patients with rumination or supragastric belching/aerophagia.

Fluoxetine in posttraumatic eating disorder in two-year-old twins

Feeding disorders of infancy or early childhood are relatively uncommon in the pediatric population. In posttraumatic eating disorder, the infant demonstrates food refusal after a traumatic event or repeated traumatic events to the oropharynx or esophagus. We present case reports of 24-month-old twin girls, A and B, who presented to our clinic with food refusal and fear of feeding. Several invasive gastrointestinal procedures were performed when they were 3 months old, and they started to refuse all solid food and some liquids soon after hospitalization. Fluoxetine 0.3 mg/kg per day (5 mg/day) was started to target their anxiety and fear about feeding. In the second month of weekly follow up, the children began to be fed without a nasogastric catheter. A significant decrease in anxiety and fear was observed during feeding. Although the use of serotonin-selective reuptake inhibitors (SSRIs) in preschool children is controversial due to the lack of empirical data in this age group, we observed clinical improvements in anxiety in these two cases. Furthermore, fluoxetine was well tolerated and no side effects were observed.

The effectiveness of risperidone in the treatment of three children with feeding disorders

Children with histories of extensive medical interventions in early childhood, especially those involving the gastrointestinal tract, are at-risk for residual feeding problems long after the medical issues have resolved. This case series describes the inpatient multidisciplinary treatment of 3 consecutive preadolescent children (ages 9, 8, and 7 years) admitted to our rehabilitation facility. Each child was admitted with a severe feeding disorder and histories of failure-to-thrive (FTT) that had required enteral nutritional interventions. Each child also had comorbid anxiety and mood symptoms. The addition of risperidone to behavioral and psychopharmacologic treatments was observed to significantly increase oral intake and accelerate weight gain. In 2 of 3 patients, assistive feeding interventions were successfully discontinued; and in a 3rd patient, enteral nutritional support was reduced by 74%. These cases suggest that risperidone may be a safe and effective adjunctive treatment, when behavioral feeding therapy is not sufficiently successful for children who have chronic and complicated medical and psychiatric presentations.

Effect of cisapride on gastric emptying in premature infants with feed intolerance

OBJECTIVE

To assess the effect of cisapride on gastric emptying and gastro-oesophageal reflux (GOR) symptoms in preterm infants with feed intolerance.

METHODS

Sixteen preterm infants (gestational age 24-35 weeks) with feed intolerance were enrolled in the study. Infants were randomized to receive 7 days of cisapride 0.2 mg/kg four times a day, immediately followed by 7 days of placebo or vice versa. Gastric emptying was measured using the [13C]-octanoic acid breath test prior to study entry and repeated on day 5, 6 or 7 after randomization and 5, 6 or 7 days after crossover. The symptoms of GOR were monitored during the study period using a standardized reflux chart. Weight was recorded daily.

RESULTS

There was no change in gastric emptying in infants prescribed cisapride (gastric half-emptying time (t1/2) 31.9 +/- 4.7 vs 34.2 +/- 3.9 min for placebo vs cisapride, respectively; P = 0.65). Infants on cisapride had slower growth and there was no change in reflux symptoms.

CONCLUSIONS

The use of cisapride in preterm infants with feed intolerance cannot be recommended.

Effect of growth hormone therapy on feeding problems and food intake in children with growth disorders

To assess the effect of therapeutic doses of growth hormone (GH) on the feeding problems, food intake, body fat and mealtime interactions of children with growth disorders, an age-matched group of 46 children with Turner syndrome (TS) or Silver Russell syndrome (SRS) was examined using questionnaire measures and direct observation. The children's body fat was measured using bio-electrical impedance analysis and skinfold thickness measurements. Children receiving GH consumed significantly more energy, protein, fat and carbohydrate than did the children who were not receiving GH, independent of the extent of the child's feeding problems. Children receiving GH had less body fat than did children who were not receiving GH. Children who were not receiving GH distracted their parents from the mealtime significantly more often and received more negative prompting and coaxing from their parents to eat than did children who were receiving GH. This study provides evidence to support the theory that appetite and intake is determined in part by growth and growth potential. Feeding problems seen in children with growth disorders are partly due to parental attempts to impose control over their child's intake, when their child consumes less than the parent believes to be adequate.

CONCLUSION

GH has a significant impact on both the food intake and parent-child interaction at mealtimes of children with SRS and TS.

Cisapride: a review of the evidence supporting its use in premature infants with feeding intolerance

A systematic computerized search of all databases was performed to review the scientific evidence in support of the efficacy of cisapride in reducing feeding intolerance in premature infants. Reference lists from these articles were used to identify relevant scientific literature to address important aspects of the use of cisapride. Three open prospective, uncontrolled studies were found. All studies reported improved clinical outcomes as evidenced by decreased gastric residuals, decreased incidence of vomiting, increased feeding volume, decrease in all reflux parameters measured, and increased weight gain. These observational studies reflect the current state of knowledge and have important research and clinical implications because of the profound effects of feeding intolerance on infant growth and development and on length of stay within NICUs.