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Stampfer L, Deutschmann A, Dür E, Eitelberger FG, Fürpass T, Gorkiewicz G, Heinz-Erian P, Heller I, Herzog K, Hopfer B, Kerbl R, Klug E, Krause R, Leitner E, Mache C, Müller T, Pansy J, Pocivalnik M, Scheuba E, Schneditz G, Schweintzger G, Sterniczky E, Zechner E, Hauer AC, Högenauer C, Hoffmann KM. Causes of hematochezia and hemorrhagic antibiotic-associated colitis in children and adolescents. Medicine (Baltimore) 2017; 96:e7793. [PMID: 28816966 PMCID: PMC5571703 DOI: 10.1097/md.0000000000007793] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Diseases causing hematochezia range from benign to potentially life-threatening. Systematic pediatric data on the causes of hematochezia are scarce. We studied the underlying causes and long-term outcome of hematochezia in children. We further investigated the relevance of antibiotic-associated hemorrhagic colitis in children, especially if caused by Klebsiella oxytoca.Infants, children, and adolescents with hematochezia were recruited prospectively. Patients were grouped according to age (<1 year, 1-5 years, 6-13 years, >14 years). In addition to routine diagnostics, K oxytoca stool culture and toxin analysis was performed. We collected data on history, laboratory findings, microbiological diagnostic, imaging, final diagnosis, and long-term outcome.We included 221 patients (female 46%; age 0-19 years). In 98 (44%), hematochezia was caused by infectious diseases. Endoscopy was performed in 30 patients (13.6%). No patient died due to the underlying cause of hematochezia. The most common diagnoses according to age were food protein-induced proctocolitis in infants, bacterial colitis in young children, and inflammatory bowel disease in children and adolescents. Seventeen (7.7%) had a positive stool culture for K oxytoca. Antibiotic-associated colitis was diagnosed in 12 (5%) patients: 2 caused by K oxytoca and 2 by Clostridium difficile; in the remaining 8 patients, no known pathobiont was identified.Infections were the most common cause of hematochezia in this study. In most patients, invasive diagnostic procedures were not necessary. Antibiotic-associated hemorrhagic colitis caused by K oxytoca was an uncommon diagnosis in our cohort. Antibiotic-associated colitis with hematochezia might be caused by pathobionts other than C difficile or K oxytoca.
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Affiliation(s)
- Laura Stampfer
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Andrea Deutschmann
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Elisabeth Dür
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Franz G. Eitelberger
- Division of General Pediatrics and Adolescent Medicine, Hospital Wels-Grieskirchen, Wels
| | - Theresia Fürpass
- Microbiologic Laboratory, Institute of Pathology, General Hospital Hochsteiermark, Leoben
| | | | | | - Ingrid Heller
- Institute of Microbiology, Medical University Innsbruck, Innsbruck
| | - Kathrin Herzog
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Barbara Hopfer
- Division of Pediatrics and Adolescent Medicine, General Hospital Hochsteiermark, Leoben
| | - Reinhold Kerbl
- Division of Pediatrics and Adolescent Medicine, General Hospital Hochsteiermark, Leoben
| | - Evelyn Klug
- Institute of Pathology, Hospital Oberwart, Oberwart
| | - Robert Krause
- Department of Internal Medicine, Medical University Graz
| | - Eva Leitner
- Institute of Hygiene, Microbiology and Environmental Medicine
| | - Christoph Mache
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | | | - Jasmin Pansy
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University Graz
| | - Mirjam Pocivalnik
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Eva Scheuba
- Division of General Pediatrics and Adolescent Medicine, Hospital Wels-Grieskirchen, Wels
| | - Georg Schneditz
- Institute of Molecular Biosciences, Karl-Franzens University Graz, Graz
| | - Gerolf Schweintzger
- Division of Pediatrics and Adolescent Medicine, General Hospital Hochsteiermark, Leoben
| | - Edith Sterniczky
- Division of Pediatrics and Adolescent Medicine, Hospital Oberwart, Oberwart
| | - Ellen Zechner
- Institute of Molecular Biosciences, Karl-Franzens University Graz, Graz
| | - Almuthe C. Hauer
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
| | - Christoph Högenauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Karl Martin Hoffmann
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz
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Huang CC, Lai MW, Hwang FM, Yeh YC, Chen SY, Kong MS, Lai JY, Chen JC, Ming YC. Diverse presentations in pediatric Meckel's diverticulum: a review of 100 cases. Pediatr Neonatol 2014; 55:369-75. [PMID: 24685339 DOI: 10.1016/j.pedneo.2013.12.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/13/2013] [Accepted: 12/09/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Our objective was to analyze demographics and characteristics of Meckel's diverticulum with different manifestations in pediatric patients. METHODS This is a retrospective study in children with symptomatic Meckel's diverticulum who underwent resection between September 1998 and October 2010. The diagnosis was confirmed by surgery and pathology. Demographic characteristics, manifestations, Meckel's scan results, surgical and histological findings were analyzed. RESULTS One hundred symptomatic Meckel's diverticula were identified in 74 boys and 26 girls aged from one day to 18 years old over 13 years. Depending on whether or not obstruction occurred, the patients were classified into two categories. Each category was further subdivided into two diagnostic groups: 17 intussusception and 24 non-intussusception bowel obstruction in the obstructive category and 44 gastrointestinal bleeding and 15 diverticulitis and/or perforation in the non-obstructive category. The sex discrepancy was higher in the non-obstructive category than in the obstructive category (male-to-female, 4.36 vs. 1.73, p < 0.05). Forty-one of 44 patients with gastrointestinal bleeding underwent a Meckel's scan with a high positive rate (92.7%). The ectopic tissues were identified in 73 patients and included 61 gastric type, two pancreatic type and 10 mixed type. Ectopic tissues were more prevalent in non-obstructive category (p < 0.05) with ectopic gastric tissue even more pronounced (p < 0.01). Ectopic pancreatic tissue was significantly more prevalent in intussusception (p < 0.01). Laparoscopic surgery was performed more frequently in Meckel's diverticulum with non-obstructive symptoms (p < 0.001). CONCLUSION Diverse presentations in pediatric Meckel's diverticulum are affected by different ectopic tissue types and male sex. Laparoscopic surgery is widely used for children with non-obstructive symptoms.
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Affiliation(s)
- Chen-Chuan Huang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Fang-Ming Hwang
- Department of Education, National Chiayi University, Chiayi, Taiwan
| | - Yu-Chen Yeh
- Institute of Education, National Chiao Tung University, Hsinchu, Taiwan
| | - Shih-Yen Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Man-Shan Kong
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jin-Yao Lai
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jeng-Chang Chen
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Ching Ming
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Moravej H, Dehghani SM, Nikzadeh H, Malekpour A. Lower Gastrointestinal Bleeding in Children: Experiences From Referral Center in Southern Iran. JOURNAL OF COMPREHENSIVE PEDIATRICS 2013. [DOI: 10.17795/compreped-8423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Diagnostic and therapeutic tricks in a rare case of pediatric ileal congenital arteriovenous malformation. J Pediatr Gastroenterol Nutr 2010; 51:90-2. [PMID: 20512053 DOI: 10.1097/mpg.0b013e3181d6df68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Evaluation of arterial phase MDCT for the characterization of lower gastrointestinal bleeding in infants and children: Preliminary results. AJR Am J Roentgenol 2010; 194:496-9. [PMID: 20093615 DOI: 10.2214/ajr.08.2225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to prospectively evaluate the accuracy of MDCT for the characterization of occult lower gastrointestinal bleeding in infants and children. SUBJECTS AND METHODS MDCT examinations were prospectively performed on 27 patients (2l boys, six girls; age range, 2 months-18 years). Patients with known causes of lower gastrointestinal bleeding were excluded from the study. Nonionic contrast medium was administered in an amount based on body weight. Images were obtained with a 16-MDCT scanner. For the arterial phase the section thickness was 1 mm; beam pitch, 1; and reconstruction interval, 0.7 mm. The scans were examined for abnormal vessels and extravasation of contrast medium. Two radiologists independently reviewed the images. The sensitivity, specificity, and diagnostic accuracy of MDCT were assessed with the pathologic findings or the final diagnosis as the reference standard. RESULTS Twenty of 27 patients had abnormal MDCT findings: arteriovenous malformation in 17 patients and Meckel's diverticulum in three patients. Contrast extravasation was identified in four patients. Surgery was performed on 13 of the 27 patients, and the diagnosis was otherwise confirmed in two additional patients. In these 15 cases, the sensitivity, specificity, and diagnostic accuracy of MDCT were 82%, 50%, and 74%. The interobserver difference was not significant (McNemar exact test, p = 0.063). CONCLUSION MDCT can be used to identify the location and source of lower gastrointestinal bleeding in infants and children.
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Abstract
Lower gastrointestinal bleeding in young adults is rare. Clinical diagnosis can be delayed because of obscured origin. Immediate and late patient clinical outcome is determined by the blood loss and risks of transfusion. The authors present a rare case of nodular lymphoid hyperplasia presenting as massive gastrointestinal bleed.
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Abstract
OBJECTIVE This study was done to assess the role of rigid sigmoidoscopy in diagnosis and prognosis of children with chronic and minor lower gastrointestinal bleeding. METHODS Retrospective review of the clinical notes of children under 15 years of age with minor and chronic lower gastrointestinal bleeding who had rigid sigmoidoscopy and biopsy between October 1998 and April 2002 at Liaquat Medical College Hospital, Hyderabad, Pakistan. Demographic data, clinical presentation, morbidity, sigmoidoscopic and histopathological findings were analysed to determine the role of rigid sigmoidoscopy in the management of rectal bleeding in children. RESULTS A total of 229 sigmoidoscopic examinations were carried out in 207 children with a mean age of 6 years. Seventy-seven per cent (160) of children were symptomatic for a year or more. Causes of bleeding were juvenile colorectal polyps (155 cases; 75%), non-specific proctitis (38 cases; 18%), solitary rectal ulcer (seven cases; 3.5%), lymphoid nodular hyperplasia (six cases, 3%) and foreign body (betel nuts) impaction (one case; 0.5%). Polyps were mostly in the rectosigmoid region and solitary in 136 (88%) children. All polyps were removed by rigid sigmoidoscopy. Histological examination of 137 polyps revealed juvenile type in 136 (99%) cases and low-grade dysplastic changes in one patient. Non-specific proctitis (n = 38) was confirmed histologically in 92% (n = 35) of cases and it was self-limiting in 86% of cases. Other findings include solitary rectal ulcer in seven, lymphoid nodular hyperplasia in six and telangiectasic (pyogenic) granuloma in one patient. CONCLUSION Rigid sigmoidoscopy was useful in diagnosis, treatment and prognostic evaluation of children with chronic and minor lower gastrointestinal bleeding. Final diagnosis was confirmed by histopathology.
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Affiliation(s)
- P Mandhan
- Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad, Pakistan.
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Abstract
Lower gastrointestinal bleeding is a common problem in the practice of general pediatrics. The differential diagnosis can be extensive and varies according to the age of the child. A specific diagnosis can usually be made with a thorough history, physical examination, simple laboratory investigations, and appropriate diagnostic studies. Treatment should be directed at the underlying cause. In most children, bleeding ceases spontaneously, and only supportive therapy is necessary. If there is evidence of hypovolemia, the patient must be hemodynamically stabilized, active bleeding stopped, and recurrent bleeding prevented.
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Affiliation(s)
- Alexander K C Leung
- University of Calgary, Alberta Children's Hospital, 1820 Richmond Road SW, Calgary, Alberta, Canada T2T 5C7.
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Li WC, Ko SF, Kuo HW, Huang SC, Liang CD, Tiao MM. Different management options for anaphylactoid purpura with intussusception: a case report. Acad Emerg Med 2001; 8:1005-7. [PMID: 11581090 DOI: 10.1111/j.1553-2712.2001.tb01103.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intussusception is the most common surgical indication of anaphylactoid purpura. About 50% of cases are of the ileo-ileal type. Surgical intervention, rather than radiologic reduction, is preferable for older children suffering from anaphylactoid purpura with intussusception, where a lead point lesion is often found. The authors report a case of anaphylactoid purpura with intussusception with spontaneous reduction, and postulate that subsequent to relieving bowel-wall edema using antihistamine and steroid therapy, the ileo-ileal intussusception may spontaneously reduce.
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Affiliation(s)
- W C Li
- Department of Pediatrics, Chang Gung Children's Hospital, 123 Ta-Pei Road, Niaosung, Kaohsiung, Taiwan, ROC
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Lee KH, Yeung CK, Tam YH, Ng WT, Yip KF. Laparascopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children. J Pediatr Surg 2000; 35:1291-3. [PMID: 10999681 DOI: 10.1053/jpsu.2000.9299] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND/PURPOSE Gastrointestinal bleeding (GIB) in children with no identifiable source found after upper endoscopy and colonoscopy or GIB of obscure origin can pose a great management problem for pediatric surgeons. The recent advent of laparoscopy in children has provided a useful solution. METHODS The authors reviewed their experience of using laparoscopy in the management of 17 children (13 boys) with GIB of obscure origin over an 8-year period. The mean age was 9.8 years (range, 3 to 17 years). RESULTS In all patients, upper endoscopy and colonoscopy results did not show a bleeding source. Pertechnetate technetium Tc 99m scan showed positive uptake in 6 patients. Of these, 4 were found on laparoscopy to have a Meckel's diverticulum, 1 had intestinal duplication, and the remaining patient had nodular lymphoid hyperplasia at the terminal ileum. Ten patients had a negative pertechnetate scan. Of these, 3 had a Meckel's diverticulum, 1 had lymphoid hyperplasia, 1 had intestinal duplication, 1 had vascular enteritis, and 4 had normal findings on videolaparoscopy. Pertechnetate scan was not performed in 1 patient and, on laparoscopy, it turned out to be Meckel's diverticulum. Laparoscopic-assisted small bowel resection was performed successfully in all patients with Meckel's diverticulum, intestinal duplication, and nodular hyperplasia. Conversion to open surgery was required in the patient with extensive ileal vascular enteritis secondary to Henoech Scholein purpura. All patients, including the 4 with normal findings on laparoscopy, had made uneventful recovery without further episode of bleeding. CONCLUSION Laparoscopy is a useful diagnostic as well as therapeutic tool in children with GIB of obscure origin.
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Affiliation(s)
- K H Lee
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital
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Affiliation(s)
- F Andiran
- Hacettepe University, Medical Faculty, Department of Pediatric Surgery, Ankara, Turkey
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Abstract
Vascular anomalies are an uncommon cause of gastrointestinal bleeding in childhood. Confusing nomenclature has made objective comparisons of published cases difficult and has interfered with an established consensus regarding diagnosis and therapeutic modalities. The purpose of this study was to clarify the situation by reviewing the records of all children who had intestinal vascular anomalies who were referred to our institution from 1975 to 1995. Thirteen lesions were identified in nine children (five boys and four girls). The median age at clinical onset was 8 years. Only two patients presented with a complex syndrome (Klippel-Trenaunay, 1; Osler-Rendu-Weber, 1). Diagnosis, location, and extension of these anomalies was only possible by angiography, which indicated that seven patients had isolated venous malformations and two had arteriovenous malformations. Because the lesions did not involve the serosa, intraoperative localization was a major problem. The main findings were a few slightly dilated mesenteric veins. Treatment was conservative in four children and surgical in five. Pathological findings on resected bowel demonstrated dilated and abnormal veins in the mucosa and submucosa. Selective angiography should not be delayed in patients with gastrointestinal bleeding if results of all other investigations are negative. Because these lesions are rarely recognizable on operative inspection, precise preoperative angiographic localization of intestinal vascular anomalies is essential to allow for a safe and limited resection of the involved bowel segment. Based on a better understanding of the natural history of these lesions, a classification of vascular anomalies of intestines in children is proposed.
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Affiliation(s)
- B Frémond
- Department of Radiology, Hôpital Sainte-Justine, Montreal, Quebec, Canada
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 7-1997. A 14-year-old girl with recurrent painless rectal bleeding. N Engl J Med 1997; 336:641-8. [PMID: 9032051 DOI: 10.1056/nejm199702273360908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Shennak MM, Tarawneh MM. Pattern of colonic disease in lower gastrointestinal bleeding in Jordanian patients: a prospective colonoscopic study. Dis Colon Rectum 1997; 40:208-14. [PMID: 9075759 DOI: 10.1007/bf02054990] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was developed to document causes of rectal bleeding of Jordanian patients and compare them with results from several parts of the world. METHODS Diagnostic and therapeutic colonoscopy was used as a first-line investigation on 701 consecutive Jordanian patients presenting with rectal bleeding. When indicated, technetium 99m-labeled red blood counts or selective angiography were used also. RESULTS Most common causes according to frequency were hemorrhoids, polyps, ulcerative colitis, amebic colitis, neoplasm, diverticulosis, anal fissure, Crohn's disease, and arteriovenous malformations. CONCLUSIONS This is the first study addressing this problem from this part of the world. Findings were different from many other results published in western and eastern studies in certain disease entities.
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Affiliation(s)
- M M Shennak
- Department of Internal Medicine, Faculty of Medicine, University of Jordan, Amman
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Weisselberg B, Dayal Y, Thompson JF, Doyle MS, Senior B, Grand RJ. A lamb-meat-based formula for infants allergic to casein hydrolysate formulas. Clin Pediatr (Phila) 1996; 35:491-5. [PMID: 8902326 DOI: 10.1177/000992289603501002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ten infants with colitis due to milk protein allergy, presenting as hematochezia, whose symptoms did not resolve with the use of hydrolyzed cow-milk-based formulas, were treated with a modular lamb-meat-based formula (LOP). The patients were followed up for 3 months to 5 years. Prompt resolution of symptoms was achieved. In three patients, increased levels of creatinine and blood urea nitrogen and mild metabolic acidosis were noted, all returning to normal after the protein intake was lowered. All patients had normal growth. Seven patients were able to tolerate cow milk protein or soy at age 9-15 months. The LOP formula is well tolerated and is a safe alternative formula for infants allergic to cow milk hydrolysate formula.
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Affiliation(s)
- B Weisselberg
- Department of Pediatric Gastroenterology, New England Medical Center Hospital, Boston, MA 02111, USA
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