Screening of celiac disease in Down syndrome - Old and new dilemmas

Celiac disease (CD) is a common and well defined autoimmune disorder caused by gliadin and related proteins of wheat, rye, and barley. Epidemiologic studies confirmed that CD is highly associated with other autoimmune diseases and with Down syndrome (DS). The symptomatic form of CD in patients with DS is more frequent than asymptomatic forms. However, growth impairment, anemia, intermittent diarrhea, and constipation are symptoms and signs typically of children with DS without CD. Late identification of the disease can lead to various complications, sometimes even very severe. Therefore, systematic screening for CD is essential in the management of children and adolescents with DS. Many medical organizations recommend screening in this group of patients. However, current policy statements vary in their recommendations for screening and there is still a need for establishing uniform diagnostic criteria.

Effect of gluten-free diet on the growth and nutritional status of children with coeliac disease

INTRODUCTION

Gluten-free diet (GFD) presents the basis of coeliac disease (CD) treatment. If strictly applied, the disorders of the small bowel mucosa and other disease signs rapidly resolve.

OBJECTIVE

The goal of the study was to evaluate the effect of GFD on the growth and nutritional status of children with the classical form of CD. In addition, we analyzed the differences between these parameters with the duration and the patients' compliance with GFD.

METHODS

The study goals were achieved on a sample of 90 children, 56 female and 34 male, aged 0.5-7.5 (1.53 +/- 1.05) years, with the classic CD diagnosed on the basis of typical pathohistological findings of the small bowel mucosa and clinical recovery of patients on GFD. The duration of the patients' follow-up was 1.08-8.75 (3.03 +/- 1.14) years, i.e. until the age of 2.5-15 (4.59 +/- 1.78) years. The initial and control values of body height (BH) in relation to matched values for age and gender were expressed in percentiles, while the deviation in body weight (BW) for the matched values of height and gender was expressed in percentages. The referent haemoglobin (Hb) rate in blood, as a laboratory indicator of nutritional status in children aged up to 5 years was > or = 110 g/L, and for those aged above 5 years it was > or = 115 g/L Compliance with GFD was based on the pathohistological findings of the small bowel mucosa or determination of tissue transglutaminase.

RESULTS

Over the studied period, the effect of GFD was highly significant, both on the increase of BH percentiles (37.62 +/- 26.26 vs. 57.22 +/- 25.29; p < 0.001), and on the decrease of BW deficit 11.58 +/- 10.80 vs. 0.89 +/- 8.194; p < 0.001). After the treatment period, none of the children showed slowed growth rate or BW deficit above 20%, while BW deviation ranging between 10-20% in relation to the referent values was registered in 17 (18.19%) and the excess of over 20% in 2 patients. In 86 (95.56%) patients, control Hb values in blood were normal, while mild anaemia was registered in 4 patients, all compliant with GFD. The difference between the compliant and non-compliant patients with GFD was not detected either in BH percentiles (p = 0.586) or in BW percentage deviation as compared to standard values (p = 0.516) or in blood Hb values (p = 0.445). In addition, differences between the children on GFD lasting over and below 3 years were not detected either in BH percentiles (p = 0.915) or in BW deviation percentages in relation to the ideal rate (p = 0.476).

CONCLUSION

GFD applied for 1-3 years has a highly significant effect on the growth rate and nutritional status of children with the classical form of CD. Significant differences in these parameters of the disease were not detected between strictly compliant and non-compliant patients on GFD.

Lactose intolerance in infants with gluten-sensitive enteropathy: frequency and clinical characteristics

INTRODUCTION

Secondary lactose intolerance (SLI) belongs to the rarer manifestations of gluten-sensitive enteropathy (GSE). It occurs in more severe forms of the disease and its presence contributes significantly to the degree of its expression.

OBJECTIVE

The goal of the study was to determine the frequency of SLI in infants with clinically classic form of GSE, as well as its relationship with the duration, severity and age at the diagnosis of the basic disease and the degree of small bowel mucosa damage.

METHODS

The study was based on a sample of 42 infants, 30 female and 12 male, aged 7-12 months (x = 9.98 +/- 1.69), with a clinically classic form of GSE. The diagnosis of GSE was established based on the characteristic pathohistological appearance of small bowel mucosa and clinical improvement of patients on gluten-free diet, while SLI on pathological lactose or milk tolerance test. The assessment of basic disease severity was based on body mass divergence in relation to the standard value, as well as on Hb and serum iron levels, while the degree of small bowel mucosa damage was determined according to the modified Marsh criteria.

RESULTS

SLI was verified in 8/42 or 19.05% of patients. In addition to the symptoms and clinical signs of GSE, all the patients with SLI also featured the problems characteristic of lactose tolerance disorders, i.e. watery diarrhoea, borborygmus and meteorism occurring after milk meals. In addition, all had perianal erythema (6 with erosive changes), as well as destructive enteropathy (5 subtotal and 3 total). The difference in the duration of the basic disease, age at diagnosis, as well as in the degree of body mass deviation from the standard value between the lactose-tolerant and lactose-intolerant infants was not found. In addition, no difference in Hb and serum iron levels or in the degree of small bowel mucosa damage was found between the two groups.

CONCLUSION

Our findings indicate that SLI presents a relatively frequent occurrence in infants with clinically classic GSE, as well as that it occurs independently to the duration, severity and age at diagnosis of the basic disease and the degree of small bowel mucosa damage.

A case of human monocytic ehrlichiosis in Serbia

INTRODUCTION

Ehrlichiosis is a bacterial zoonosis transmitted by hematophagous arthropods--ticks. In humans, it occurs as monocytic, granulocytic, and ewingii ehrlichiosis. Pathological process is based on parasitic presence of Ehrlichia organisms within peripheral blood cells--monocytes and granulocytes.

CASE OUTLINE

Fifty-two year old patient was admitted to hospital due to high fever of over 40 degrees C that lasted two days, accompanied with chills, muscle aches, malaise, loss of appetite, headache, confusion, breathing difficulties, and mild dry cough. The history suggested tick bite that occurred seven days before the onset of disease. Doxycycline was introduced and administered for 14 days, causing the disease to subside. Indirect immunofluorescence assay was used to analyze three serum samples obtained from this patient for Ehrlichia chaffeensis antibodies, and peripheral blood smear was evaluated for the presence of Ehrlichia and Ehrlichia aggregation into morulae.

CONCLUSION

Ehrlichiosis should be considered in each case where there is a history of tick bite together with the clinical picture (high fever, chills, muscle aches, headache, generalized weakness and malaise, and possible maculopapular rash). The presence of Ehrlichia chaffeensis antibodies was confirmed in a patient with the history of tick bite, appropriate clinical picture and indirect immunofluorescence assay. This confirmed the presence of human monocytotropic ehrlichiosis, a disease that is uncommonly identified in our country.

When to screen children with Down syndrome for celiac disease?

The coexistence of Down syndrome (DS) and celiac disease (CD) has been reported in many studies. In our study, we examined 82 children with DS aged 8 months to 8.6 years for the existence of CD using serological markers immunoglobulin A (IgA) and immunoglobulin G (IgG) transglutaminase antibodies, followed by follow-up determination of total IgA levels. In four children who were positive for one of the above-mentioned antibodies, enteric biopsy has been performed that showed absence of CD. Our findings raise doubt about the need for obligatory serological screening of children with DS aged <8 years.

Coeliac disease as the cause of resistant sideropenic anaemia in children with Down's syndrome: case report

INTRODUCTION

Coeliac disease (CD) is a permanent intolerance of gluten, i.e., of gliadin and related proteins found in the endosperm of wheat, rye and barley. It is characterized by polygenic predisposition, autoimmune nature, predominantly asymptomatic or atypical clinical course, as well as by high prevalence in patients with Down's syndrome (DS) and some other diseases.

OUTLINE OF CASES

We are presenting a girl and two boys, aged 6-7 (x = 6.33) years with DS and CD recognized under the feature of sideropenic anaemia resistant to oral therapy with iron. Beside mental retardation, low stature and the morphological features characteristic of DS, two patients had a congenital heart disease; one ventricular septal defect and the other atrioventricular canal. In two patients, trisomy on the 21st chromosome pair (trisomy 21) was disclosed in all cells, while one had a mosaic karyotype. All three patients had classical laboratory parameters of sideropenic anaemia: blood Hb 77-89 g/l (x = 81.67), HCT 0.26-0.29% (x = 0.28), MCV 69-80 fl (x = 73), MCH 24.3-30 pg (x = 26.77) and serum iron 2-5 micromol/L (x = 4.0). Beside anaemia and in one patient a mild isolated hypertransaminasemia (AST 67 U/l, ALT 62 U/l), other indicators of CD were not registered in any of the children. In addition, in all three patients, we also detected an increased level of antibodies to tissue transglutaminase (atTG) of IgA class (45-88 U/I) so that we performed endoscopic enterobiopsy in order to reliably confirm the diagnosis of CD. In all three patients, the pathohistological finding of the duodenal mucosa specimen showed mild to moderate destructive enteropathy associated with high intraepithelial lymphocyte infiltration, cryptic hyperplasia and lympho-plasmocytic infiltration of the stroma. In all three patients, the treatment with a strict gluten-free diet and iron therapy applied orally for 3-4 months resulted in blood count normalization and the correction of sideropenia. Serum level of the atTG-IgA, repeated after a 12-month diet, was also normal.

CONCLUSION

CD should be taken into consideration in all cases of sideropenic anaemia resistant to iron oral therapy in children with DS.The diagnosis of CD implicates corresponding pathohistological confirmation, while the treatment of sideropenic anaemia and its complications, beside iron preparations, also requires compliance with a gluten-free diet.

Prednisone for the Treatment of Acute Nonspecific Mesenteric Lymphadenitis

BACKGROUND: Acute nonspecific mesenteric lymphadenitis refers to a common pediatric problem that has no specific treatment. CASE REPORT: In our study, we describe seven children presenting with abdominal pain as the main symptom of a disease. All patients were treated with prednisone 1 mg/kg (max 40 mg daily) for a maximum of 5 days. In addition, we evaluated the intensity of the pain using a numeric rating scale and achieved a clinically important difference in acute pain relief of 85.3%. After administering corticosteroid therapy, the abdominal pain resolved after 1.7 (1–4) days in all children without any other disturbances. CONCLUSION: In selective patients with mesenteric lymphadenitis, prednisone can be used as an acceptable form of treatment to reduce the duration of abdominal pain.

[Comparison of different methods of temperature measurment in children]

INTRODUCTION

The consequences of failing to notice fever in children can be serious. On the other hand, false positive reading can result in unnecesery investigation or diagnostic approach. The aim of this study was to compare different ways of body temperature measurement.

MATERIAL AND METHODS

This prospective study was carried out on Pediatric Department of General Hospital in Subotica during 10 months (March-December 2006). In 263 children aged 1 month to 18 years of age, the body temperature was obtained from 4 measurement sites: tactile assesment, forehead and ear by electronic thermometer, rectal temperature in small children (up to 2 years of age) or axillar temperature in older children by mercury thermometer. Tympanic thermometry was considered as a standard for fever detection.

RESULTS

The sensitivity of rectal temperature to detect fever is 46.67%, while specificity is 92.19%. The sensitivity of fever detection by electronic thermometry on the forehead is lower according to rectal thermometry - 36.08%, while specificity is 95.18%. The lowest values ofsensitivity are recorded in axillar thermometry (35.82%), specificity is 90.20%. The correlation coefficient is higher between tympanic and rectal temperature measurement (r=0.5076, p<0.0005), than between tympanic and forehead measurements (r=0.5076, p<0,0005), while the lowest was between tympanic and axillar mesurement sites (r=0.4933, p<0.0005).

CONCLUSIONS

The results of our study and literature data show that the most accurate methods of thermometry are rectal measurement of body temperature in small children and tympanic thermometry in children over 2 years of age.

Risk Factors for Relapse and Mortality of Clostridium Difficile-Associated Diarrhea

AIM: The aim of the present paper was to identify prognostic factors for relapse and mortality in patients with hospital-acquired infections caused by Clostridium difficile.MATERIAL AND METHODS: This study included 133 patients with healthcare facility-associated disease caused by C. difficile. The medical records of all patients with their clinical history and laboratory data were analyzed.RESULTS: Patients with one onset of disease were 105 (78.9%), 28 (21.1%) experienced a relapse and seven (5.2%) patients not survived infection. The average age in our patients was over 65 years (64.5 years in the survived patients and 78.8 in patient who died, p = 0.01). All of patients had received antibiotic treatment (cephalosporins – 83.4%, aminoglycosides – 21.5% and penicillins – 20.3%) and 40.6% of patients received acid-reducing therapy. There was no difference between patients with one onset of disease/patients with relaps; and survived/died in number of administered antibiotics, duration of administration, administration of acid-reducing treatment or length of hospital stay (p > 0.05). CRP levels were significantly higher in the group of patients who died compared with recovered (p < 0.001). CONCLUSION:  C. difficile-associated diarrhea is a common nosocomial disease with high relapse, and significant mortality rate particularly in the elderly.

[Erythromycin in therapy of cyclic vomiting syndrome]

Cyclic vomiting syndrome is an insufficiently understood disorder which manifests itself in stereotypical episodes of vomiting with no detectable organic cause. Considering its unknown aetiology, drugs borrowed from various medication classes are applied in the therapy of this disorder, with variable success. Among other medicaments, erythromycin is also used in treatment of cyclic vomiting syndrome. This is a case study in which the application of erythromycin led to the prevention of attacks of cyclic vomiting syndrome. Our case report presents how periodical erythromycin therapy in two-week intervals at expected attack periods in a girl led to disappearance of cyclic vomiting. Adverse effects of erythromycin did not show up.

[Corticosteroid therapy in Henoch-Schönlein gastritis]

INTRODUCTION

Henoch-Schönlein purpura (HSP) is the most common vascular disease of childhood. It is a multisystem disease most commonly affecting the skin,joints, gastrointestinal tract, and kidneys, but other organs may be affected, too. Gastrointestinal involvement occurs in approximately 65-90% of patients, ranging from mild symptoms such as abdominal pain, nausea, and vomiting, to more severe manifestations such as gastrointestinal bleeding and intussusception. In most cases, HSP spontaneously resolves without treatment. The use of corticosteroids is controversial and usually reserved for severe systemic manifestations. Some authors suggest that the abdominal pain and gastrointestinal hemorrhage of HSP may respond to steroids, with some suggesting that there is a benefit in their use and describing a regimen.

CASE OUTLINE

This is a case report of HSP in a fourteen-year-old boy with abdominal pain and hematemesis. Upper endoscopy showed an edematous and erythematous change in the body of the stomach and purpuric lesions in the duodenum, while multiple erosions were found in the antral area. Parenteral corticosteroid therapy with gastric acid secretion inhibitor administration led to regression of gastrointestinal symptoms on the seventh day, with relapses on the fourth and sixth day. Peroral administration of corticosteroids and gradual decrease of daily doses started on the eighth day of abdominal symptoms. New purpuric skin rashes appeared during six weeks.

CONCLUSION

Corticosteroid therapy with gastric acid secretion inhibitors showed a positive effect in our patient with a severe form of HSP accompanied by abdominal pain and gastrointestinal hemorrhage.

Lactose intolerance in children and adults

Lactose is a disaccharide found in milk and dairy products. Children and adults with lactose intolerance are unable to tolerate significant amounts of lactose because of an inadequate amount of the enzyme lactase. The condition occurs in three main types: primary, secondary, and primary adult-type hypolactasia. The use of milk in the diet of these individuals may lead to appearance of the irritable bowel syndrome. In persons with lactose intolerance symptoms include diarrhoea, dominated by abdominal colic, loud peristaltic sounds, increased flatulence and meteorism. A diagnosis of lactose intolerance can usually be made with a careful history, elimination of lactose from the diet, lactose tolerance test, hydrogen breath test and genetic testing. In the absence of appropriate tests in patients with suspected primary adult-type hypolactasia, diagnosis can be made as in patients with food allergy. Treatment is based on the restriction of lactose intake with the use of fermented milk products. However, especially for children, if milk and dairy products are eliminated from the diet, it is important to ensure D vitamin and calcium supplementation.

[Evaluation of body height and body weight in relation to growth in children in the North Backa region]

INTRODUCTION

Body weight and height in regard to age present an important indicator for evaluation of health status in children. The aim of this study was to evaluate body weight and height in regard to age in children of the North Backa Region (Subotica, Backa Topola and Mali Idos) compared to reference values.

MATERIAL AND METHODS

Results of transversal anthropometric measurements performed from 1995-1998 of body weight and body height of 25.790 children aged 1-18 from Health Centers in North Backa Region have been statistically processed by software "CHILD". Body weight and height in regard to age were evaluated by standard deviation, according to international World Health Organization reference values and National Center for Health Statistics (NCHS/WHO).

RESULTS

Body weight was established (+2 standard deviation) in 9.33% children, while 1.14% had decreased body weight from -2 standard deviation. Obesity, as well as undernourishment, dominated among children from village Mali Idos. Body height higher than +2 standard deviation was registered in 8.07% children, mostly among boys from Backa Topola. Body height lower than -2 standard deviation was found in 2.10% children of our region.

DISCUSSION

Obesity in children aged 1-18, in our region is higher than in the children from UN regions and subregions. Only Russia has worse results generally speaking. In regard to the WHO Global Database of underweight children, we can say that in our children it is hardly present.

CONCLUSION

These findings reflect the need for prospective growth monitoring of children in our area and for health improvement through nutrition intervention programs.

[Nutritional status of children in the North Backa Region based on the body mass index]

INTRODUCTION

Monitoring nutritional status of children at a population level represents an important index of the nutritional quality and quantity in a certain period of time. The aim of this paper was to determine the body mass index (BMI kg/m2) and evaluate the nutritional status of children in the North Backa Region (Subotica, Backa Topola and Mali Idos).

MATERIAL AND METHODS

A transversal anthropometric study examining body weight and height during a mass screening of children in Health centers in the North Backa Region, 25.790 children aged 1-18 have been examined in the period 1995-1998. Evidence and statistical evaluation of data have been processed using the software "CHILD" determining the percentile values of BMI and nutritional status according to reference values of the First National Healts and Nutrition Examination Survey (NHANES 1).

RESULTS

Analyzing the nutritional status of children aged 6-18 in the North Backa Region we found 4.39% boys and 5.41 girls with BMI < P5 as underweight, moderate underweight with BMI P5-15 were 7.28% boys and 6.96% girls, whereas normal nutritional status (BMI P15-85) was found in 67.13% boys and 67.25% girls. 12.77% of boys and 11.78% of girls were overweight (BMI P85-95) and obesity (BMI > P95) was registered in 8.46% boys and 8.60% girls. Using the same software and based on results for the whole group of children aged 1-18, reference values were calculated for BMI as a regional reference data which can be used in everyday public health setting.

DISCUSSION

This research is the first examination of the nutritional status of children at a population level in the North Backa Region in regard to BMI. This model of nutritional status monitoring in children using the above mentioned software will be used at a national level.

CONCLUSION

These results show an inadequate nutritional status of children in the North Backa Region which can be associated with unbalanced nutrition and life style. Therefore, permanent monitoring of the nutritional status in children has been established in order to take adequate preventive measures to realize nutrition of children and adolescents.

Efficacy of Prednisone in Children with Acute Nonspecific Mesenteric Lymphadenitis: A Pilot Study

BACKGROUND

Acute nonspecific mesenteric lymphadenitis (ANML) is a common cause of acute abdominal pain in children with no specific treatment.

METHODS

A total of 13 patients (6 boys, 7 girls) aged 7.3 (5-13.5) years with severe acute abdominal pain were evaluated using ultrasonography and laboratory tests to establish the diagnosis of ANML. They were treated with prednisone 1 mg/kg (max 40 mg daily) for a maximum of 5 days. The intensity of abdominal pain was evaluated before and after treatment using a numeric rating scale.

RESULTS

All patients had pain scores above 6/10 before, and below 4/10 after treatment with prednisone. Intensity of abdominal pain after treatment for 1-5 days decreased significantly (p < 0.001), with no recurrence at follow-up within 3 months. All other pre-existing signs and symptoms, such as nausea, vomiting, anorexia, fever, diarrhea, and constipation were found to disappear with no adverse effects of corticosteroid therapy.

CONCLUSION

These results suggest that the treatment with prednisone in selective patients with ANML can reduce the duration of abdominal pain.

[Potential risk factors for children in the family diet]

INTRODUCTION

It has been proven that high-energy diet with predominance of saturated fatty acids, cholesterol, animal proteins and sugar increases disease incidence. The aim of this study was to determine the potential risk factors of family diet of schoolchildren in Subotica.

MATERIAL AND METHODS

Evaluation of energy and nutrient intake in family diet (n = 357 families with schoolchildren) was examined by a Food Consumption Questionnaire during 7 days in February-March 1998. Data were elaboreted using a software "NUTQ". The potential nutritive risk factors were determined according to Recommended Dietary Allowances (RDA) index of dietary adequacy, as well as Population Nutrition Goals.

RESULTS

Mean energy intake was 2197 kcal, where proteins made 14.64%, fats 41.39% and carbohydrates 43.97%. Mean intake of dietary saturated fatty acids (S) was 11.17%, of polyunsaturated fatty acids (P) 14.39%, of monounsaturated fatty acids 15.82%, dietary cholesterol 82.68 g/1000 kcal, dietary fiber 10.67 g daily, while the P/S ratio was 1.28. Analytical questionnaire of schoolchildren family diet shows that daily about 7.5% of children take in more than 30% of fats, 7% of them over 300 mg of dietary cholesterol, 65% of them over 10% of refined sugars, 50% of them over 10% of saturated fatty acids and all of them more than 6 g of NaCl and less than 20 g of dietary fiber a day.

DISCUSSION

According to WHO recommendations, the average daily energy intake values are appropriate for boys, but exceeding for girls aged ten. Domination of meat, meat products, fats, oils, sugars, as well as mean intake of total fats, saturated fatty acids, potassium and sodium, represent potential nutritive risk factors for developing cardiovascular diseases, which are at the first place of morbidity and the second cause of mortality. In regard to our data from 1998, which have shown that among schoolchildren (n = 478) 10.04% boys and 11.47% girls were obese, 8.55% boys and 6.42% girls were overweight, 9.15% had hypercholesterolemia, 14.83% had hypertrigliceridemia and 17.28% had elevated level of LDL-cholesterol, we have to admit that preventive actions regarding healthy nutrition policy is necessary in our society.

CONCLUSION

Nutritional risk factors in diet of average children in Subotica demand prompt preventive actions in order to prevent nutrition disorders.

Coeliac disease and collagenous colitis

A thirteen and a half year old girl and her father were both investigated because of chronic watery diarrhoea and growth failure or weight loss. Both were diagnosed as having coeliac disease. In the daughter, collagenous colitis was also diagnosed. The father had colonic collagen deposition with inflammatory changes as well. Both improved on gluten-free diets, but colonic collagen deposition persisted.

[Arias icterus--prolonged unconjugated hyperbilirubinemia caused by breast milk]

INTRODUCTION

Breast milk jaundice occurs in 1-2% of healthy breast-fed newborns and young infants. It develops as the result of liver immaturity and the inhibitory effect of mother's milk to the clearance of unconjugated bilirubin.

OBJECTIVE

The paper analyzes variations in the level and length of unconjugated hyperbilirubinemia in breast-fed infants.

METHOD

The study was conducted on a sample of 29 young infants (19 male) with breast milk jaundice. All infants were born on time, by natural delivery and without complications. All were on breast-feeding only and developed optimally. None of the infants had either haemolysis or any other disease associated with unconjugated hyperbilirubinemia.

RESULTS

All infants had physiological jaundice in the first week after birth, with unconjugated bilirubin level of 166-260 micromol (201.50 +/- 36.37 micromol). In the postneonatal period the highest bilirubin level was recorded in the fifth week of life and was 87-273 micromol (166.82 +/- 45.06 micromol), which then spontaneously, without interruption of breast-feeding, gradually declined. The decrease of the unconjugated fraction of serum bilirubin between the fourth and fifth week was significant, and after that highly significant. The normalization of serum bilirubin occurred in the seventh and thirteenth week (10.41 +/- 1.68 micromol). Negative consequences of hyperbilirubinemia were not noted in any of the infants.

CONCLUSION

Breast milk jaundice presents a harmless and transitory disorder of bilirubin metabolism. It occurs in healthy breast-fed neonates and young infants. Jaundice is most marked in early neonatal period, and then it gradually declines and disappears between the seventh and thirteenth week.

A Case Report of Early-Onset Frey's Syndrome in an Infant

The appearance of flushing in the territory of the auriculotemporal nerve after ingestion of foods with a sweet, salty, or sour flavor could suggest Frey's syndrome, especially if the infant has a history of obstetric trauma. This rare and benign condition requires no diagnostic exploration or treatment. A 3-month-old male infant presented with facial flushing since he was 6 weeks' old. Episodes of flushing were stereotypical, over the zone innervated by the left auriculotemporal nerve. They started 10 to 15 seconds after the beginning of the feeding and disappeared after 15 to 20 minutes. At the time of the onset of facial erythema, the infant was exclusively bottle feeding. Diagnosis of Frey's syndrome was made on historical and clinical grounds, and no further testing was needed. Flushing gradually started to fade at the age of 5 months and completely disappeared after 8 months. Introducing solid food did not cause any deterioration of facial erythema. Early recognition of Frey's syndrome is important to avoid unnecessary investigation and therapy. On the other hand, our reported case warns that Frey's syndrome may occur in very early infancy without ingestion of solid food.