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Eastern Journal of Medicine 15 (2010) 146-150

K. W. So et al / Erythromycin and gastrointestinal dysmotility

Review Article

Erythromycin and gastrointestinal dysmotility in preterm infants
King Woon So, Pak Cheung Ng
Department of Pediatrics, The Chinese University of Hong Kong, Hong Kong, China

Abstract. Gastrointestinal dysmotility is a common condition in preterm infants due toimmature development of gastrointestinal peristalsis. Erythromycin, with its motilinomimetric effect, has been used to facilitate enteral feeding in preterm infants. Various regimens, including prophylaxis versus rescue treatment and low dose versus high dose therapy have been investigated. The results suggest that intermediate or high doses oral erythromycin used as rescue treatment is associatedwith a shorter time to attain full enteral feeding, a decrease in the duration of parenteral nutrition requirement, a reduction of parenteral nutrition-associated cholestasis and a decrease in catheter-associated recurrent septicemia. Although none of the studies reported any sinister adverse effects, neonatologists should use this class of drug cautiously and selectively in preterm infants withrefractory functional gastrointestinal dysmotility. Key words: Gastrointestinal dysmotility, enteral feeding, preterm, very low birthweight infants

1. Introduction
Functional gastrointestinal (GI) dysmotility is a common condition in preterm infants and may manifest as an increase in gastric residue after feeding, marked abdominal distension or constipation (1). As feeding intolerance is alsoone of the early presenting symptoms of necrotising enterocolitis (NEC), advancement of enteral feeding may need to be stopped and nutrition of the infant requires to be supported parenterally. However, prolonged use of parenteral nutrition can predispose to catheterrelated nosocomial infection, cholestasis, osteopaenia, poor intestinal growth and prolonged hospitalization (2). In an attempt tominimise these devastating complications, various medications, including metoclopramide and cisapride have been tried to improve the GI motility in these infants. However, none of these treatments has been proven to be useful and many are associated with serious adverse effects. After several case series studies have shown that erythromycin could facilitate enteral feeding in preterm infants (2-4),10 randomised controlled
*Correspondence: Professor Pak C. Ng Department of Pediatrics, Level 6, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China E-mail:

trials (RCTs) have so far been conducted in the last decade (5-14). This article examines the results of these studies, and assesses the efficacy and safety of erythromycin as a prokinetic agent in preterminfants.

2. Pathophysiology
Co-ordinated contraction of smooth muscle that propels food forward through the intestinal tract is regulated both by neural and hormonal control (15). There are two types of small intestinal motor patterns in adults. The first type is the simultaneous contraction at different levels of the GI tract when food is ingested. This results in mixing and churning of ingestedfood with gastric secretion, and thus, facilitates the presentation of nutrients to the mucosal surface of the intestine. The second type occurs during fasting. The stomach and small intestine exhibit cyclic groups of caudally migrating contractions known as the migrating motor complex (MMC) (16). This phenomenon is thought to sweep residual products of digestion towards the colon and serves as a‘housekeeper’ (17). The MMC is primarily controlled by the local enteric nervous system (18) and modulated by hormones, including motilin (19), somatostatin (20) and pancreatic polypeptides (21). Motor patterns of the GI tract in preterm infants are different to adults (22). Very few infants


K. W. So et al / Erythromycin and gastrointestinal dysmotility

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