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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 218-221

Milk curd syndrome with goat's milk: Revisited


Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission05-Sep-2022
Date of Decision10-Oct-2022
Date of Acceptance12-Oct-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Rahul Gupta
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_98_22

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  Abstract 


Milk curd syndrome is an infrequent cause of intestinal obstruction in neonates and early infancy. We are adding to the literature an extremely rare case of milk curd syndrome in a 3-month-old infant who was being fed with goat's milk. A 3-month-old infant presented with features of intestinal obstruction. The patient used to pass a few pellets such as small, firm, white-colored stools after every 2 to 3 days often requiring enema. The baby was fed with goat's milk. Abdominal radiographs suggested large bowel obstruction. The conservative treatment with rectal washes failed. Exploration revealed dilated small bowel with the presence of very dense, inspissated, sticky, and white-colored intraluminal material in the terminal ileum and throughout the colon. Multiple attempts were made to milk the contents distally and finally out of the rectum but failed. A transverse loop colostomy was performed and inspissated milk curds were milked out. The outcome was favorable. The diagnosis of milk curd obstruction should be considered in neonates and infants with signs of the terminal ileum or large bowel obstruction fed with unmodified animal milk, for example, goat's milk (as seen in our case) or formula feeds.

Keywords: Formula feed, goat's milk, inspissated milk syndrome, intestinal obstruction, milk curd syndrome


How to cite this article:
Gupta R. Milk curd syndrome with goat's milk: Revisited. Saudi J Health Sci 2022;11:218-21

How to cite this URL:
Gupta R. Milk curd syndrome with goat's milk: Revisited. Saudi J Health Sci [serial online] 2022 [cited 2023 Feb 7];11:218-21. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/3/218/362385




  Introduction Top


Milk curd syndrome is an infrequent cause of intestinal obstruction in neonates and early infancy.[1] Intestinal obstruction is due to the inspissation of formula feeds or dried cow's milk. It is very rare after feeding with unmodified animal milk, especially goat's milk.[2] The presentation in the majority of neonates is shortly after feeds with features of small intestinal obstruction, at around 4 to 10 days.[3],[4],[5] Its diagnosis is almost always intraoperative (presence of inspissated milk curds) as it mimics other causes of neonatal intestinal obstruction.[3],[4],[5] A very rare case of milk curd syndrome in a 3-month-old infant (late presentation) with signs of large bowel obstruction being fed with unmodified goat's milk is presented. A high index of suspicion should be present for the milk curd syndrome, in any infant with features of neonatal intestinal obstruction along with a history of feeding with unmodified animal milk.


  Case Report Top


A 3-month-old infant, weighing 2050 g presented to us with abdominal distension for the past 2 and ½ months, along with constipation and occasional vomiting. The features were suggestive of intestinal obstruction. The patient was a firstborn male child, born prematurely <37 weeks, and received neonatal intensive care unit after birth for 3 weeks for respiratory distress, neonatal jaundice, and sepsis. There was a history of passing meconium for a few days after birth. The patient used to pass a few pellets such as small, firm, white-colored stools after 2 to 3 days often requiring enema. The baby was fed with goat's milk.

On examination, the child was afebrile, dehydrated, pale, and hemodynamically unstable with a pulse rate – 140/min, respiratory rate – 44/min, and SO2 94% without oxygen support. The abdomen was moderate to severely distended with visible bowel loops. Perineal examination revealed penoscrotal hypospadias with severe chordee and bifid scrotum; the anus was normal and the rectum was empty. Laboratory values revealed anemia (hemoglobin (Hb) 9.6 g% and hematocrit 36.9%), and leukocytosis (total leukocyte count 18,820/mm3). Renal functions were deranged (serum urea 60 mg/dl and serum creatinine 1.3 mg/dl); serum electrolytes and liver functions were normal. Sepsis screen C-reactive protein as positive. The patient was resuscitated with intensive care unit care.

Abdominal radiographs suggested large bowel obstruction [Figure 1]. Abdominal ultrasound confirmed loaded colon and rectum with normal small bowel loops. Ultrasound of the brain revealed increased echogenicity in the peri-sulcal region.
Figure 1: Abdominal radiograph shows dilated large bowel loops with loaded fecal matter in the entire colon

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To remove the inspissated fecal matter, 0.9% saline enemas followed by gastrografin enemas were given, which were negative. Since the baby did not decompress with repeated attempts of enema and had progressively increasing abdominal distension, laparotomy was planned. Preoperative optimization was performed. Exploration revealed dilated small bowel with the presence of very dense, inspissated, sticky, and white-colored intraluminal material in the terminal ileum and throughout the colon. Multiple attempts were made to milk the contents distally and finally out of the rectum but failed [Figure 2]. A transverse loop colostomy was performed and inspissated milk curds were milked out [Figure 2]. The contents were curdled/inspissated milk. The patient did well postoperatively, despite the initial ileus; oral feeds were gradually initiated, and finally was discharged on the 7th postoperative day. The baby is under follow-up and is gaining weight.
Figure 2: Intraoperative photographs show nonyielding inspissated milk curds in the sigmoid colon (a), exteriorization and fixation of the transverse colonic loop filled with curds (b and c) creation of colotomy (d), and removed inspissated milk curds (e and f)

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  Discussion Top


The milk curd syndrome or milk plug syndrome or inspissated milk syndrome is a rare cause of intestinal obstruction in neonates and infants.[1] Intestinal obstruction is caused by the inspissation of formula feeds or dried cow's milk.[1] This entity was first described by Cook and Rickham in 1969.[2],[3] It is a type of functional intestinal obstruction in premature and extremely low birth weight neonates. The male-to-female ratio is 5:1. Usually, there is a normal discharge of meconium after birth.[2],[3] Intestinal obstruction appears usually between the 2nd and 16th day after birth with a peak incidence between 4 and 10 days. Late presentation at 6 weeks of age has been reported. In the present case, the presentation was late owing to a lack of awareness and delayed referral.[4] The inspissated milk curds are usually found in the distal part of the ileum and colon. In the index case, the majority of curds were present in the colon. In the Western world, this condition was more commonly seen when formula feeds were manufactured by just drying cow's milk, in the 1970 s.[3],[5],[6] It was seen in neonates who were fed with concentrated formula feeding, fortified cow's milk with high-fat content, and high-caloric fortified expressed breast milk.[7],[8] The presumed pathogenesis of this entity is due to variation in the absorption of the water and milk solids, and the formation of intraluminal calcium soap, which leaves a firm gritty bolus, stuck in the terminal ileum and colon.[2]

The predisposing factors are prematurity, low birth or very low birth weight, use of concentrated formula feeds high in calories and protein, additives such as calcium, and use of reconstituted powdered cows' milk.[5],[6],[7],[8] The composition of artificial milk feeding formula in association with transitory absorption deficiency of amino acids, and the possibility of a temporarily insufficient excretion of bile acids have been postulated.[8] Furthermore, formula feeds with a high casein/whey ratio and casein have been associated as the major contributing factor in its development.[9],[10]

The proposed hypothesis for intestinal obstruction in the index case is “relative early drying out” of the intestinal content. Unmodified goat's milk contains high protein (300% of human milk) and high content of calcium and phosphorus. This greater solute load of goat's milk coupled with premature gastrointestinal physiology precipitated intestinal obstruction in the present case. This theory holds with cows' milk also.[9]

The presentation in the majority of patients is with features of bowel obstruction in the early neonatal period (shortly after feeding) with abdominal distension, emesis, increased gastric residuals, abdominal mass, and sometimes bloody stools (50% cases).[10] The diagnosis should be suspected in a neonate who after progressing normally with the passage of meconium becomes obstructed around 4 to 10 days.[3],[4],[5] Delayed presentation is associated with gastrointestinal perforation. The condition mimics meconium ileus in patients with distal ileal obstruction and Hirschsprung's disease, especially total colonic aganglionosis. Abdominal radiographic features and ultrasound with carefully taken history are a pointer toward with condition, but diagnosis is almost always intraoperative with the presence of inspissated milk curds.[6],[7],[8],[9],[10]

Management should be individualized. Medical treatment includes fluid resuscitation, control of sepsis, and institution of saline and/or gastrografin enemas. Effective clearance of inspissated milk curds and resolution of symptoms has been reported from the West.[6] Other researchers have reported a low success rate.[5]

Exploration (celiotomy) is mandatory after the failure of conservative treatment.[1],[2] In our case, most of the inspissated milk curds were present from the transverse to the sigmoid colon. This was in contrast to the terminal ileum, being the most common site, as per the previous literature.[1],[2] Furthermore, extension into the colon has been reported.[1],[2]

Ideally, the ileal bolus is broken up and milked through the ileocecal valve into the colon, but it might fail as seen in the present case. Enterotomy at the site of inspissation, either ileum or colon (as seen in our case), and removal of the bolus with or without diverting stomas have been described.

In conclusion, the diagnosis of milk curd obstruction should be considered in neonates and infants with signs of the terminal ileum or large bowel obstruction fed with unmodified animal milk or formula feeds. An accurate assessment of the initial stool pattern and evaluation of the type of milk or formula feeds would help diagnose the entity. A history of feeding with goat's milk in an infant with intestinal obstruction is a pointer toward milk curd syndrome. Early involvement and referral to a pediatric surgeon should be sought. Fat absorption is best from breast milk and is highly recommended in neonates.

Acknowledgment

We are sincerely thankful to the Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India for helping in our endeavor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wagener S, Cartwright D, Bourke C. Milk curd obstruction in premature infants receiving fortified expressed breast milk. J Paediatr Child Health 2009;45:228-30.  Back to cited text no. 1
    
2.
Gupta R, Tiwari K, Sharma CS, Goyal RB. Milk curd syndrome in a neonate fed with Goat's milk. J Neonatal Surg 2017;6:88.  Back to cited text no. 2
    
3.
Lewis CT, Dickson JA, Swain VA. Milk bolus obstruction in the neonate. Arch Dis Child 1977;52:68-71.  Back to cited text no. 3
    
4.
Cremin BJ. Functional intestinal obstruction in premature infants. Pediatr Radiol 1973;1:109-12.  Back to cited text no. 4
    
5.
Flikweert ER, La Hei ER, De Rijke YB, Van de Ven K. Return of the milk curd syndrome. Pediatr Surg Int 2003;19:628-31.  Back to cited text no. 5
    
6.
Navarro A, Melo C, Pinzón JC, Méndez NA, López-Pérez GA. Intestinal obstruction caused by milk curds in newborns. Cir Pediatr 1993;6:91-2.  Back to cited text no. 6
    
7.
Watanabe T, Takahashi M, Amari S, Ohno M, Sato K, Tanaka H, et al. Olive oil enema in a pre-term infant with milk curd syndrome. Pediatr Int 2013;55:e93-5.  Back to cited text no. 7
    
8.
Pochon JP, Stauffer UG. The milk curd syndrome. Helv Paediatr Acta 1978;33:53-7.  Back to cited text no. 8
    
9.
Soliman GZ. Comparison of chemical and mineral content of milk from human, cow, buffalo, camel and goat in Egypt. Egypt J Hosp Med 2005;21:116-30.  Back to cited text no. 9
    
10.
Schreiner RL, Brady MS, Ernst JA, Lemons JA. Lack of lactobezoars in infants given predominantly whey protein formulas. Am J Dis Child 1982;136:437-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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