Elsevier

Journal of Pediatric Surgery

Volume 41, Issue 12, December 2006, Pages 2056-2058
Journal of Pediatric Surgery

Cow's milk protein allergy presenting with Hirschsprung's disease–mimicking symptoms

https://doi.org/10.1016/j.jpedsurg.2006.08.031Get rights and content

Abstract

Background

Pediatric surgeons often encounter neonates who present with Hirschsprung's disease (HD)–like symptoms and plain x-ray findings, but respond well to conservative treatment. During our investigation of the etiology of this condition, which we named “benign transient nonorganic ileus of neonates” (BTNIN), we noticed that BTNIN included cases of cow's milk allergy (CMA). Therefore, a prospective study of the identity of BTNIN and CMA was conducted.

Methods

Cow's milk allergy was diagnosed when a baby showed HD-like symptoms after oral feeding, and a drug-induced lymphocyte stimulation test was positive for cow's milk with a titer of more than 300%.

Materials

Of 38 neonates with suspected HD, a surgical disorder was excluded by plain x-ray in 9, intestinal atresia was diagnosed in 3, and the remaining 26 were enrolled in this study.

Results

Of 26 cases, 9 were diagnosed as HD by manometric studies and 17 as CMA. Thirteen of 17 CMA cases had been fed with breast milk and 4 with formula milk.

Conclusion

The proportion of CMA in the cases presenting with HD-like symptoms in the neonatal period is much higher than what we expected, and most cases of BTNIN are caused by CMA. If HD is ruled out, CMA should be considered.

Section snippets

Background

A substantial number of neonates present with Hirschsprung's disease (HD)–like symptoms and plain x-ray findings, which, however, respond well to conservative treatment and are associated with no long-term residual gastrointestinal (GI) symptoms. Therefore, once HD is ruled out, little attention is paid to this condition by pediatric surgeons and neonatologists. Unlike other transient functional intestinal obstruction, such as meconium-related ileus [1], this condition occurs mostly in

Definition of BTNIN

Benign transient nonorganic ileus of neonates was defined as nonorganic ileus of neonates excluding HD, HD-allied disorders, and meconium-related ileus [1]. Inclusion criteria for nonorganic ileus were defined as follows: (1) the patient was referred to the Department of Pediatric Surgery of Osaka Medical Center for Maternal and Child Health with suspected HD; (2) an upright plain x-ray showed dilatation of the colon with a diameter greater than that of the lumbar vertebrae, along one third of

Results

Of 26 cases, 9 were diagnosed as HD by manometric studies, which were confirmed by histologic examination of surgical specimens. Seventeen were diagnosed as CMA by the diagnostic criteria. All the cases presented with marked abdominal distention, 7 of them presented with vomiting including 3 cases with bilious vomiting, and severe constipation and poor weight gain were reported in 1 each. The onset of symptoms was within the first 3 days of life in 3, and between 14 and 30 days in the others.

Discussion

Cow's milk allergy is not rare in infancy; epidemiologic studies suggest that CMA affects 2% to 7.5% of infants [6], [7]. However, well-defined syndromes, such as protein-losing enteropathy and colitis, account for only 5% of CMA in infancy [8], and the vast majority of cases of CMA present with poorly defined and diverse symptoms including regurgitation and/or vomiting [9], chronic constipation [10], and allergic colitis [11]. Therefore, GI symptoms caused by CMA are often overlooked because

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Presented at the 39th Annual Meeting of the Pacific Association of Pediatric Surgeons, May 14–18, 2006, Taipei, Taiwan.

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