Prokinetic Agents
Prokinetic agents should ideally enhance esophageal peristalsis and accelerate gastric emptying, while decreasing the number and duration of transient lower esophageal sphincter relaxations. There are no medications available that specifically target transient lower esophageal sphincter relaxations, although this relaxation is recognized to be the most important pathophysiologic mechanism of reflux. To date, the effectiveness of commercially available prokinetic agents in children is unproven and not recommended for routine use. In addition, a number of prokinetic agents may have common, serious side effects such as cardiac arrhythmias and central nervous system complications. Putnam et al1 reported that parkinsonian reactions and tardive dyskinesia may occur in up to 30% of patients taking metoclopramide and may be irreversible. The FDA released a black box warning in February 2009 stating that it is not recommended for prolonged (>2 months) use except in rare cases. The 2018 Guidelines recommend against routine use of prokinetic agents to treat pediatric GERD.
1Putnam PE, Orenstein SR, Wessel HB, Stowe RM. Tardive dyskinesia associated with use of metoclopramide in a child. J Pediatr. 1992;121(6):983–985