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Suggest treatment for inflammatory bowel disease in an infant

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Posted on Mon, 25 Jul 2016
Question: My son is eight months old, six months adjusted, born two months preemie due to placental abruption. He has had severe reflux since birth and is now on Prilosec, 20 mls per day, carafate, 1.5 mls three times per day and now has been introduced to probiotics to see if they will help. He is the happiest baby and will just start screaming for hours and every couple days projectile vomit.

The doctor has agreed he will do an upper endoscopy at my request if these probiotics do not help in a few days. I mentioned to his first gi doctor, but forgot at our2nd dr visit last week to tell him that the baby has had white pieces in his poop. I told the other doctor wondering if it was the prilosec beads undigested and they said they would have dissolved and that it was not that. We have a strong family history of IBS, ulcerative colitis and Crohns and I want to be sure we are doing everything necessary yet not too extremely aggressive for my eight month old son. Any suggestions please? Thanks so much! XXXXXXX
doctor
Answered by Dr. Sumanth Amperayani (20 minutes later)
Brief Answer:
Please answer my questions - so that I can guyide you better

Detailed Answer:
Hi....I understand your concern. I understand that he is already on anti-reflux measures for GER and on Omeprazole and Sucralfate. But inflammatory bowel disease is an entity you can diagnose only if there is high index of suspicion. Otherwise the diagnosis might get unnecessarily delayed, at the same time, we should not be over aggressive in subjecting a kid to invasive investigations. Please answer my questions so that I can guide you better.

Questions:

1. What was the birth weight and what is the current weight and length (BOTH THESE ARE VERY IMPORTANT)? PLEASE MENTION HIS EXACT DATE OF BIRTH TOO. I NEED THIS TO CALCULATE HIS CENTILES OF GROWTH PARAMETERS PRECISELY.

2. How is the attaining of developmental milestones?

3. Is the stool oily and floats in the pan?

4. Is there any color change in the hair or skin?

5. Is there any history of recurrent serious infections?

6. Does he bend his neck backwards while he has those screaming episodes?

7. Did he pass motion (meconium) within 24 hours of birth?

8. Has at any point of time - FECAL CALPROTECTIN test - been done for your child?

Get back to me with answers so that I can guide you further.

Regards - Dr. Sumanth
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumanth Amperayani (10 minutes later)
Hi!
He was born 11/4/2015 at 4.1 lbs and 17 inches long. He is currently 17 lbs 10 oz and 26 inches long.
He has hypotonia but is in physical therapy 1x weekly. He is meeting his developmental milestones such as rolling over and is trying to sit up independently. He babbles and says mama and dada and laughs hysterically when prompted.
His stool is not oily. He is either constipated with harder pieces or looser stool occasionally with a few mucus streaks.The last few weeks he has had the white pieces which have been the size of say sunflower seeds.
There have been no hair or skin color changes. He has had severe eczema. He doesnt get recurrent infections but was diagnosed with macroecephaly at four months of age. He was diagnosed with BESS and they said that the fluid and its location are benign.
He arches his back and bends his neck back. He also flails his arms and legs while screaming.
He did not pass meconium that we were made aware of.
I am not aware of the test you mentioned so can not verify if it has been done. We do have a history of MRSA in the family and he tested positive in his nasal passages at birth and at around five months of age. Thank you so much!
doctor
Answered by Dr. Sumanth Amperayani (24 minutes later)
Brief Answer:
He definitely endoscopy - please go ahead

Detailed Answer:
Hi...If you have not already provided me with the history of IBD, I would have asked for it in my inquiry. He definitely needs endoscopy and also a fecal calprotectin test before going ahead with endoscopy. I feel it is not being over aggressive in investigating him. I will give you reasons for this -

Reasons why endoscopy is justified -

1. He is failing to thrive in both length and weight (though he was born preterm..still this is low).

2. Strong family history of inflammatory bowel disease (IBD).

3. He is already having symptoms related to upper gastrointestinal system.

4. Though on anti-reflux measures he is still symptomatic.

5. Diagnosis of IBD is almost always based on high index of suspicion which we should have in your son's case for sure.

I have few more questions -

1. Can you upload the sunflower seed sized white specks if you have an image with you?

2. Did you subject that particular stool sample for examination?

3. When you say strong family history of IBD - is it his immediate family or extended family or only in relatives circle.

Please get back to me with answers.

Regards - Dr. Sumanth

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumanth Amperayani (23 minutes later)
Hi! I just took a picture of a stool from earlier last evening. Yuk! LOL. I have downloaded it. Note the pieces are white, not yellow... and the only sample that was given to the dr was a couple months back at least when we saw mucus not white. They were supposedly just checking for a milk or protein allergy. Now we see the white pieces.

My older son, 23 was diagnosed with UC and has his entire colon removed at age 16 as even Remicaid would not help him with symptoms etc. My nephew had a bowel obstruction at age 19 due to Colitis. My mom, his grandma has IBD. Me and my husband both have reflux. My half brother has Crohns. My uncle has UC as well, just not as bad. It is very rampant in my family. They have not mentioned failure to thrive in fact tell me he is chubby for his length and is gaining well? I do agree strongly that he is very symptomatic and it is getting frustrating. We switched GI doctors to ensure we had one who would actually move forward as this has been going on for several months at minimum Thanks!
doctor
Answered by Dr. Sumanth Amperayani (23 minutes later)
Brief Answer:
Your son needs work up for Inflammatory bowel disease definitely

Detailed Answer:
Hi....Your son needs work up for Inflammatory bowel disease definitely.

My suggestions -

1. Fecal calprotectin.

2. Upper and lower GI endoscopy along with a biopsy for histopathological examinatioin.

3. CBC, CRP and ESR. blood tests to be done.

I wish your kid a speedy recovery. If you need any future medical consultation and suggestions, I will be glad to help. You can approach me at the following link. Once the page opens there will be an option below my image as – ASK ME A QUESTION – click on it. Please find the link below -

www.healthcaremagic.com/doctors/dr-sumanth-amperayani/67696

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Sumanth Amperayani

Pediatrician, Pulmonology

Practicing since :2003

Answered : 8348 Questions

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Suggest treatment for inflammatory bowel disease in an infant

Brief Answer: Please answer my questions - so that I can guyide you better Detailed Answer: Hi....I understand your concern. I understand that he is already on anti-reflux measures for GER and on Omeprazole and Sucralfate. But inflammatory bowel disease is an entity you can diagnose only if there is high index of suspicion. Otherwise the diagnosis might get unnecessarily delayed, at the same time, we should not be over aggressive in subjecting a kid to invasive investigations. Please answer my questions so that I can guide you better. Questions: 1. What was the birth weight and what is the current weight and length (BOTH THESE ARE VERY IMPORTANT)? PLEASE MENTION HIS EXACT DATE OF BIRTH TOO. I NEED THIS TO CALCULATE HIS CENTILES OF GROWTH PARAMETERS PRECISELY. 2. How is the attaining of developmental milestones? 3. Is the stool oily and floats in the pan? 4. Is there any color change in the hair or skin? 5. Is there any history of recurrent serious infections? 6. Does he bend his neck backwards while he has those screaming episodes? 7. Did he pass motion (meconium) within 24 hours of birth? 8. Has at any point of time - FECAL CALPROTECTIN test - been done for your child? Get back to me with answers so that I can guide you further. Regards - Dr. Sumanth