50 Years Ago in T he J ournal of P ediatrics: Foreign Body in the Stomach of a Premature Infant

Abstract

McCollough WE. J Pediatr 1962;60:277-9 This report by McCollough highlights the multifactorial etiology of bezoars in preterm infants. In contrast to swallowed foreign bodies (like coins, pins, and batteries), a bezoar in the gastrointestinal tract forms through the clumping of materials, which in normal circumstances are degraded, digested, absorbed, and easily transported. A preterm infant of 33 weeks' gestational age received nutrition via an enteral feeding tube and suffered from pneumonia. Subsequently, hematemesis developed in the baby, and a gastric ulcer was diagnosed with radiography. Although the pneumonia resolved in the next days, oral feeding intolerance did not improve. A barium meal revealed a gastric bezoar. Conservative management, with frequent small volume milk feedings, was initiated, and the bezoar resolved spontaneously. Predisposing factors for the development of gastric bezoars include either delayed gastric emptying or dysmotility with stasis often occurring in combination with decreased acid production. Acute respiratory distress is associated with delayed gastric emptying, and the pneumonia in this infant may have contributed to formation of the bezoar. Dicyclomine hydrochloride, provided to the infant as a therapeutic intervention, decreases gastric acid secretion and inhibits gastrointestinal propulsive motility. Co-administered methylcellulose and aluminum hydroxide, an antacid, which can form chalky masses of aluminum phosphate precipitates, may have formed an initial nidus to promote the development of the bezoar in the stomach. It is not clearly stated whether the baby received expressed human breast milk or infant formula. Lactobezoars in newborns fed human breast milk are described. Formula for low birth weight infants have also been purported to cause lactobezoars. Subsequent studies investigated the effects of infusion rate, volume, osmolarity, caloric density, fat, and protein composition of formulas on gastric emptying. Preterm infant formulas are now predominantly whey-based, resulting in easier digestibility and more rapid gastric emptying compared with casein-based products. The number of reported cases of bezoar in newborns has decreased, most likely because improvements in the composition of preterm infant formula and the introduction of alternatives to antacids (histamine-2 receptor antagonists, proton pump inhibitors). However, a bezoar should still be considered in the differential diagnosis of non-bilious vomiting and food intolerance in premature infants.