SUMMARY Nineteen diagnostic peroral biopsy specimens from18children without diarrhoea, vomiting, orabdominal pain('control' children) werecompared withthose takenfrom23children withdiarrhoea ofvarying aetiology toestablish themorphometric characteristics ofjejunal mucosa inchildhood. Comparison wasalsomadewithnormaljejunal mucosafromadults. Statistical analysisofeachcharacteristic individually showed no significant difference between the'control' children andthose withdiarrhoea, butthere weresignificant differences between themucosaeof'control' children andthose ofadults: thevilli tended tobeshorter andthecrypts longer inchildren. Thirtysevenpercentofspecimens fromthe'control' children showed apartial villous atrophy, thatis, they wereabnormal byadult criteria. Discriminant analysis ofthefeatures measured showedeffective separation ofthefollowing groups:normalhistology frompartial villous atrophy inchildren, healthy adults from'control' children, andnormalhistology inadults fromnormalhistology inchildren. Morphometric measurements ofthejejunal mucosa obtained byperoral biopsy inadults havebeenexhaustively reported. Thetechniques employed have varied fromsimple measurements using linear scales andgrids'-9 touseoftheWeibeltemplate'0 to measuresurface-to-volume

Jejunal mucosal morphometry inchildren withand without gutsymptoms andinnormal adults

Immunological studies incows' milkprotein-sensitiv e enteropathy

SUMMARY Thecriteria that areusedatpresent todiagnose cow's milkprotein sensitive enteropathy (CMPSE) arebased on an invivomilkchallenge which canbehazardous andlife threatening. We haveused an organculture modeltodetermine theusefulness ofthis technique inestablishing the diagnosis ofCMPSEon thebasis ofa single biopsy withinvitro milkchallenge. Fourteen infants withdiarrhoea clinically suspected tohaveCMPSEwerestudied prospectively. Onthebasis ofmilk challenge studies seveninfants hadCMPSE.Theyhadclinical reaction tocow's milkwithassociated histological changes anddepression ofalkaline phosphatase levels inthejejunal mucosa.Inall sevencasesparallel changes inalkaline phosphatase levels werenoted intheorganculture specimens ofinitial biopsy subjected toinvitro challenge. Thesevencontrol infants tolerated cow's milkand didnothavehistological changes. Thealkaline phosphatase levels weremoderately increased inthe jejunal mucosa infive oftheseveninfants. Thealkaline phosphatase levels intheorganculture specimens ofinitial biopsy were increased after invitro challenge inall seveninfants. Thisstudy suggests that organculture methods may beuseful intheinvitro diagnosis ofCMPSE,andalso obviate theneedforinvivo oral milkchallenges andrepeated biopsies.

Invitro diagnosis ofcow's milkprotein sensitive enteropathy byorganculture method

The possible role of cows' milk protein in prolonging diarrhoea in very young infants with acute infective enteritis was studied in 14 infants, 9 under the age of 2 months and 5 older than 6 months. Bacterial pathogens were isolated from the stools of 4 infants from the younger age group. After appropriate initial treatment the infants were maintained on a cows' milk protein-free formula. 6 weeks later jejunal biopsies were performed before and 24 hours after challenge with a low lactose cows' milk protein formula. The immunoglobulin and complement levels in the serum and duodenal juice were also estimated at these times. Attempts to isolate bacterial and viral pathogens in stools were again made in all patients. The 5 older infants clinically tolerated cows' milk protein and their pre- and postchallenge jejunal biopsies were within normal limits. However, significant histological changes were observed in the postchallenge jejunal biopsies of all 9 infants under 2 months of age. In addition, 5 of these infants developed diarrhoea. This suggests that the jejunal mucosa of very young infants previously fed a cows' milk protein-based formula and who contract infective enteritis suffers damage when rechallenged with cows' milk protein.

Cows'milkprotein-sensitiv e enteropathy Animportant factor inprolonging diarrhoea ofacuteinfective enteritis in early infancy

Aims-The primaryaim was toassess whetherthereweredifferences insymptoms,laboratory data,andoesophageal pH-metrybetweeninfants withprimary gastro-oesophageal reflux andthosewith refluxsecondary tocows'milkprotein allergy (CMSPA). Patientsand methods-96 infants (mean(SD)age 7.8(2.0) months)with either primary gastro-oesophageal reflux, reflux withCMPA,CMPA only, ornoneof these(controls) werestudied. Symptoms, immunochemical data,andoesophageal pH were comparedbetweenthefour groupsand theeffect ofa cows'milk protein-free dietontheseverity ofsymptomswasalsoassessed. Results-14 outof47(30%) infants with gastro-oesophageal refluxhad CMPA. Theseinfants hadsimilar symptomsto thosewithprimarygastro-oesophageal reflux buthigherconcentrations oftotal IgE and circulating eosinophils (p< 0.005) andIgGanti-, lactoglobulin (p< 0.003). A progressive constant reductioninoesophageal pH attheendofa feed, whichcontinued uptothenextfeed, was seenin12outof14patients with gastro-oesophageal refluxsecondary to CMPA andin24of25infants withCMPA only.No infants withprimarygastrooesophageal reflux andnoneofthecontrolshad thispattern. A cows'milk protein-free dietwas associated witha significant improvement in symptoms onlyininfants withgastro-oesophageal reflux withCMNPA. Conclusion-A characteristic oesophageal pH patternisuseful in distinguishing infantswithgastro-oesophageal reflux associated withCMPA. (Arch DisChild 1996;75:51-56)

reflux secondary tocows' milk protein allergy

entero- pathy hasbeenusedin15patients, andthefollowing setofcriteria areproposed. (1) Clinical disease (diarrhoea with orwithout vomiting) while receiving cows' milkprotein. (2)Clinical improvement on adiet free ofcows' milkprotein. (3)Normal ormildly abnormal histology ofjejunal mucosa when taken6-8weeksafter symptomssubside. (4)Histological relapse, withorwithout clinical relapse, after re-exposuretocows' milkprotein. Intolerance tocows' milk protein hasbeenreported inrecent years asacause ofpersistent diarrhoea and failure tothrive inCaucasian infants (Goldman etal., 1963; Gryboski, 1967; Freier etal., 1968; Kuitunen etal., 1975). Diagnosis hashitherto beenbased on certain clinical criteria described byGoldman etal. (1963). (1)Thedevelopment ofsymptoms which subside after dietary elimination ofmilk. (2)Symp- tomswhich recur within 48hours ofmilkchallenge. (3)Reactions tothree suchchallenges should be positive andhavea similar onset, duration, and clinical features. These criteria, while basically sound, arefrequently impractical andwebelieve leadtounderdiagnosis. Recently othercriteria havebeensuggested, the emphasis being placed onthedemonstration of intestinal mucosal damagebythetoxic effect of cows' milkprotein rather thanonclinical observa- tions (Walker-Smith, 1975; Shiner etal., 1975a, b). We haveusedbotha clinical andhistological approach tothediagnosis ofcows'milkprotein intolerance inaprospective study.

Cows'milkprotein-sensitiv e enteropathy Combined clinical andhistological criteria fordiagnosis

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Cows'milkprotein-sensitiv e enteropathy Combined clinical andhistological criteria fordiagnosis