E S P G H A N 32nd Annual Meeting; Warsaw, Poland, June 2-5, 1999
Recent results indicate that chronic gastrointestinal symptoms and histological changes of gastroesophageal reflux disease (GERD) unresponsive to standard treatments can be improved by the use of elemental formulas. GERD is common in neurologically impaired children (NIC), and the disorder is notoriously resistant to both medical and surgical treatments in this subject group. Because of prior observations in normally developed children, this investigation was designed to determine the efficacy of a dietary trial with an elemental formula on GERD in NIC who had not responded to medical and/or surgical therapy. Eight children (mean age ±SD: 53.7 ±40.9 months; 6 females) affected by cerebral palsy and having severe mental retardation were studied. Each had a long-standing history of GERD that had persisted despite standard antireflux therapies, including omeprazole in all and Nissen fundoplication in 3. The diagnosis of GERD was based on presence of typical microscopic changes of the esophageal mucosa. Subjects were fed the amino acid-based elemental formula Neocate (Nutricia) by mouth or by nasogastric tube for a minimum of 4 weeks while prior stable treatments for reflux disease were continued. Each child underwent endoscopy with esophageal biopsies and a cellobiose/mannitol sugar permeability test before and after the dietary trial. Symptomatology, endoscopy, and histology were graded using scales reflecting increasing severity with increasing grade; histology was graded by an observer who was blinded to the endoscopic findings. RESULTS: Using conventional histological criteria, esophagitis was considered moderate in 7 and mild in 1 at the beginning of the dietary trial. Five (62.5%) of the 8 patients also had an abnormal sugar permeability test, but none had an allergy history or positive skin testing to food antigens. By the end of the dietary trial, 7 of the 8 patients (87.5%) became free of their long-term complaints (regurgitation and/or vomiting, abdominal pain, chronic pulmonary aspiration). Furthermore, both endoscopic and histological findings of GERD significantly improved (p<0.01 and p<0.05, respectively using Fisher's exact test). Nevertheless, no significant changes were found in the number of esophageal mucosal eosinophils and mast-cells. After the trial, the permeability sugar test normalized in 3 of the 5 (60%) with initially abnormal studies. CONCLUSIONS: A course of a highly restricted diet with an amino acid-based formula may reverse long-standing upper gastrointestinal symptoms and resolve esophagitis in NIC who are unresponsive to conventional antireflux treatment. The mechanisms responsible for symptom and histological improvement remain uncertain, but they are not necessarily immunologic in nature.
Disclosure: The authors have no financial interest in the described products.