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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31820ae6d1
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Safety and Efficacy of High-dose Acarbose Treatment for Dumping Syndrome

De Cunto, Angela; Barbi, Egidio; Minen, Federico; Ventura, Alessandro

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Author Information

Department of Pediatrics, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy.

Received 17 September, 2010

Accepted 10 December, 2010

Address correspondence and reprint requests to Angela De Cunto, Via dell'Istria 67/1, 34100 Trieste, Italy (e-mail: angela.decunto@libero.it).

The authors report no conflicts of interest.

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Abstract

Dumping syndrome (DS) is a complication of Nissen fundoplication. Dietary strategies can ameliorate symptoms, but this approach is not always foolproof. Limited evidence reports the efficacy of acarbose for children who are unresponsive to feeding manipulations. We report 8 patients with DS aged between 7 and 24 months. In 4 of 8 nutritional strategies failed, and acarbose treatment was started. The initial dose was 25 mg for meals, and increased until postprandial glucose was stable. In 3 of 4 children the final dose was higher than previously reported, without adverse effects. Acarbose is useful to treat DS in cases of failure of dietary strategies.

Dumping syndrome (DS) has been reported as a postoperative complication of Nissen fundoplication. Typically, children with DS may have early postprandial hyperglycemia (PPH) within 60 minutes of feeding, followed by late hypoglycemia 1 to 4 hours later. The physiopathologic mechanisms of DS are poorly understood: A possible explanation is that DS results from a precipitous emptying of hyperosmolar carbohydrate-containing solutions into the small bowel with subsequent rapid glucose absorption and hyperglycemia followed by reactive hypoglycemia (1). Dietary strategies based on frequent feeding with complex carbohydrates and fat emulsion can ameliorate symptoms (2,3), but this approach is not always foolproof. Limited evidence in the literature reports the efficacy of acarbose for children who are unresponsive to feeding manipulations (4). As a matter of fact, only 8 cases are reported, with an acarbose dosage varying from 25 mg to a maximum of 50 mg (4).

We report 8 cases of children between the ages of 7 and 24 months with DS. In all but 1 DS was diagnosed after fundoplication surgery; in 1 case it followed a continuous enteral feeding in a child with Haddad syndrome. Three of 7 patients have undergone Nissen fundoplication for gastroesophageal reflux disease due to esophageal atresia. All of the children were symptomatic and the diagnosis was confirmed by oral glucose tolerance test or glycemic controls after bolus feeding. Nutritional manipulations were attempted in all of the cases and failed to control symptoms in 4 of 8 (50%). Acarbose treatment was started in the other 4 children with an initial dose of 25 mg per feeding. The dose was increased in increments of 25 mg per feeding until postprandial serum glucose was stable. In 3 of 4 cases the final dose reached to achieve the desired effect was higher than previously reported: respectively, 75 mg in 2 cases and 100 mg in another one (Table 1). Acarbose was well tolerated in all of the patients, with no side effects.

Table 1
Table 1
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To the best of our knowledge, this is the second largest series in the literature about acarbose efficacy and the only one showing efficacy and safety of higher dosages. Furthermore, DS has been reported in Haddad syndrome only once (1), and our report further emphasizes the importance of dysregulation of autonomic control in this disease.

The issue of feeding children with DS not responding to dietary treatment can be a critical and challenging one, mainly because many of these patients have a history of poor growth, feeding difficulties, and sometimes distressed families. We believe that the possibility of an efficacious treatment deserves to be reiterated, highlighting at the same time the efficacy of higher than previously reported dosages.

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REFERENCES

1. Rivkees SA, Crawford JD. Hypoglycemia pathogenesis in children with dumping syndrome. Pediatrics 1987; 80:937–942.

2. Khoshoo V, Roberts PL, Loe WA, et al. Nutritional management of dumping syndrome associated with antireflux surgery. J Pediatr Surg 1994; 29:1452–1454.

3. Borovoy J, Furuta L, Nurko S. Benefit of uncooked cornstarch in the management of children with dumping syndrome fed exclusively by gastrostomy. Am J Gastroenterol 1998; 93:814–818.

4. Ng DD, Ferry RJ Jr, Kelly A, et al. Acarbose treatment of postprandial hypoglycemia in children after Nissen fundoplication. J Pediatr 2001; 139:877–879.

Keywords:

acarbose; dumping syndrome; hypoglycemia

Copyright 2011 by ESPGHAN and NASPGHAN

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