Neonatal segmental enteritis due to cow's milk allergy
A 30-day-old boy baby was referred with abdominal distension, feculent vomiting and failure to thrive. He was born at term to a surrogate mother and weighed 3.2 kg at birth. He was started on cow's milk 6 h after birth and was discharged on the 3rd day. He was readmitted on the 7th day of life with clinical features suggestive of sepsis and probable necrotizing enterocolitis (NEC). He was managed conservatively and discharged 5 days later on infant formula and cow's milk. A few days later, he was brought back to the treating pediatrician with recurrent vomiting, abdominal distension and weight loss. Stool for reducing substances was negative. Malrotation of the gut was suspected and a barium meal was done and found to be normal. Barium enema was also normal. The C-reactive protein (CRP) was high and he was treated with intravenous antibiotics and other supportive measures. This was his third admission with clinical features of sepsis (raised CRP). Immunodeficiency was suspected and Immunoglobulin G (IgG), Immunoglobulin M (IgM) and Immunoglobulin A (IgA) were found to be normal. He was referred to our hospital to the pediatric surgery out-patient department on day 30 with gross abdominal distension and persistent vomiting. His admission weight was 2.8 kg and he was sick, wasted and dehydrated. A clinical diagnosis of HD with enterocolitis was made. He had features of acute abdomen with feculent vomiting and tenderness. X-ray of the abdomen showed dilated bowel loops. Ultrasound showed free fluid in the abdomen. Laparotomy was done. The jejunum showed features of segmental enteritis with turbid fluid and flakes in the peritoneum []. Colon was collapsed. Appendix was sent for frozen section biopsy to rule out total colonic aganglionosis. It was reported to be normal. Abdomen was closed after a wash. A diagnosis of segmental enteritis with peritonitis was made. The peritoneal fluid culture showed growth of Escherichia coli and Enterococcus faecalis and he was started on appropriate antibiotics. The general condition improved’, but the abdominal distension recurred when oral feeds were initiated. Parenteral nutrition was started. He was reviewed by the pediatric Gastroenterologist who suspected food allergy. A complete Immunoglobulin profile was done. IgG, IgM, and IgA were normal for age, but the IgE level was >315 IU/ml (N ≤ 1.5). CMPA was considered and the radioallergosorbent test (RAST) assay was done and was found to be strongly positive –6.82 (N ≤ 0.1).\nA diagnosis of segmental enteritis with peritonitis due to cow's milk allergy was made. Baby was started on a hypoallergenic formula. 48 h later, the abdominal distension started to resolve. He was on hypoallergenic infant formula and his discharge weight was 3.1 kg. His review weight at 7 months was 6.5 kg and the serum IgE had declined to normal levels.