CLINICAL CONFERENCE The Celiac Syndrome

508 PEDIAmIcs, March 1958 DR. LEVINE : The patient to be presented is an infant who had chronic diarrhea. Studies performed on this patient by Dr. Murray Davidson, Assistant Professor of Clinical Pediatrics, suggest that there are multiple factors involved in the production of the celiac syndrome. Dr. Davidson will discuss the patient’s illness and observations made. DR. MURRAY DAVIDSON: To many pediatricians the diagnosis of celiac syndrome means difficulty in absorption of nutrients. According to this concept the diagnosis cannot be made unless there is evidence of excessive stool loss of ingested material. An important contribution to our understanding of the condition has been made by the Dutch and British workers who have demonstrated steatorrhea related to the ingestion of gluten in patients with the celiac syndrome. On the other hand, to some, celiac syndrome merely implies a state of chronic diarrhea. Thus, some cases of diarrhea related to milk ingestion have been called celiac syndrome because of chronicity of symptoms. To the best of our knowledge there are no published reports of such patients in whom detailed study has revealed evidence of malabsorption or a relationship to a specific protein in milk as has been shown in the studies with gluten. In this paper it is our intention first to report a patient who fulfilled the criteria for celiac syndrome upon ingestion of a specific milk protein, and then to examine the current cI issification of the conditions which make up the celiac syndrome. D.B., a 5-week-old infant, was admitted to the New York Hospital with a history of severe and chronic diarrhea from birth, manifested while receiving evaporated and skim milk formulae as well as Nutramigen#{174}. Stool cultures failed to reveal any pathogens. Study of the urinary tract, gastrointestinal tract and adrenal function revealed no cause for diarrhea. Examination of the sweat and duodenal fluid ruled out cystic fibrosis of the pancreas. When fed a formula prepared from Sobee#{174} the infant responded with cessation of diarrhea and demonstrated a weight gain for the first time since birth. Accordingly, various diets were fed in approximately isocaloric amounts, and 48-hour stool collections were examined for fat according to the method of Wejers and Van der Kamen, nitrogen by the Kjeldahl technique, and an estimate was made of the fluid content. The intake of each diet ranged from 950 to 1200 ml daily and the dietary protein from a low of 18 gin to a high of 41 gm; the fat intake was held more constant, fluctuating only between 29 and 33 gm/day. While receiving Nutramigen#{174} the patient’s total stool output per 24 hours weighed over 150 gm and the stool fat content was 13 gin. When the formula consisted of whole milk the total stool output per 24 hours increased in excess of 200 gin and the stool fat content to 46 gin. However, with Sobee#{174} feedings the total stool output fell to about 75 gm/day and the fat content of 5 gm/day. Since the only difference between Sobee#{174}and Nutramigen#{174} is the source of protein, the protein in the latter being derived from hydrolyzed Casee#{174}, the patient was fed the same Sobee#{174} feeding as before with the addition of 9 gin of Casec#{174}per day, or one-third the amount which would furnish the prot&n derivatives contained in the Nutramigen#{174} formula. With this feeding the 24-hour stool output rose to approximately 150 gin and the stool fat content to 17 gin. During two subsequent control collections, one composed of Sobee#{174} feedings, the other a formula containing fibrinogen hydrolysate in amounts comparable to those present in Nutramigen#{174}, the stools returned to normal.