Background Symptoms of gastro-oesophageal reflux and foregut dysmotility are common in children with neurodisability and can have significant consequences. Domperidone is widely used in the management of these symptoms. In April 2014, the Medicines and Healthcare Products Regulatory Agency (MHRA) issued an alert highlighting cardiac safety concerns about domperidone. This medication was discontinued in a child with foregut dysmotility, secondary to cerebral palsy, who then developed aspiration pneumonia. This prompted literature review and analysis of current practice to develop guidelines for domperidone use.
Method Retrospective case note review of all paediatric patients (aged 0–18 years) issued domperidone prescriptions by pharmacy, over a 7 month period, at a large children’s hospital offering secondary and tertiary care.
Results Literature review revealed no studies of domperidone in the neurodisability population and limited evidence of benefit in infants with gastro-oesophageal reflux. The basis of cardiac concerns from the MHRA alert was from adult studies; those with associated cardiac co-morbidity were at particular risk.
Children with neurodisability and foregut dysmotility accounted for 29% (20/69) of all paediatric domperidone prescriptions. These patients (mean age 5.7 years) all had significant motor disability, multiple co-morbidities and enteral tube feeding. Symptoms included vomiting, distress with feeds, recurrent lower respiratory tract infections, poor weight gain and retching. Domperidone was not being used as a first line treatment; interventions before this included postural management, other anti-reflux medications, fundoplication and changes to feed type, route and regime. 74% were prescribed doses above the new maximum recommendation. 25% did not have documented review of progress and decisions relating to discontinuation were not always clear.
Guidelines were developed for domperidone prescription and ongoing review; these encompass indications, other interventions, dose recommendations and follow up.
Conclusion While safe prescribing is essential, the symptoms and complications of foregut dysmotility in children with neurodisability should not be underestimated. This review highlights the need for further evidence of risk and benefit of domperidone use in this patient population; a pragmatic trial of domperidone in this group should be considered.
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