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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 212-215

Milk curd obstruction: An increasingly common rarity?


1 Department of Paediatric Surgery, Oxford University Hospitals Trust, Oxford Children's Hospital, Oxford, United Kingdom; Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
2 Department of Paediatric Surgery, Oxford University Hospitals Trust, Oxford Children's Hospital, Oxford, United Kingdom

Date of Submission26-Apr-2019
Date of Decision01-Jul-2019
Date of Acceptance31-Jul-2019
Date of Web Publication04-Oct-2019

Correspondence Address:
Dr. Niveshni Maistry
11 Lords Ave, Randburg, 2194 Johannesburg

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_51_19

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  Abstract 


Introduction: Milk curd obstruction is a rare, yet important cause of neonatal bowel obstruction that has been seldom reported in the literature. The presentation has evolved over time: Initially being seen in formula-fed term babies, to now being more prevalent in premature babies that require milk fortification. We present a case series of four patients treated for the condition at our institution and report that there may be additional contributing factors that have not been previously described. Method: Case notes of four patients that were diagnosed with milk curd obstruction over a one-year period were retrospectively analysed. Data collected included: gender, gestational age at birth, birth weight, pre-existing gastro-intestinal pathology, previous surgeries, feeding regimens used as well as the management and outcomes of milk curd obstruction. Results: All patients included in the series were premature, with three being classified as extremely low birth weight (ELBW). All babies received fortified expressed breast milk feeds. Three patients were treated for necrotising enterocolitis (NEC) prior to being diagnosed with milk curd obstruction. Two patients had undergone surgery for abdominal pathology ahead of their diagnosis. Three of the four babies required operative management for milk curd obstruction, whilst one was successfully managed conservatively. There were no mortalities. Conclusion: Previous gastrointestinal pathology as well as previous surgery may be associated with the development of milk curd obstruction. Milk curd obstruction is becoming an increasingly significant cause of neonatal bowel obstruction and further research and investigation is required to establish patterns of causation.

Keywords: Milk curd obstruction, milk fortification, necrotizing enterocolitis, neonatal bowel obstruction, prematurity


How to cite this article:
Maistry N, Wagener S. Milk curd obstruction: An increasingly common rarity?. J Clin Neonatol 2019;8:212-5

How to cite this URL:
Maistry N, Wagener S. Milk curd obstruction: An increasingly common rarity?. J Clin Neonatol [serial online] 2019 [cited 2019 Nov 15];8:212-5. Available from: http://www.jcnonweb.com/text.asp?2019/8/4/212/268588




  Introduction Top


Milk curd obstruction is an infrequent cause of neonatal bowel obstruction that was initially described in term babies fed with cow's milk-based formulas.[1],[2] As the process of formula production was refined and altered to better suit neonatal physiology, the incidence of the condition decreased. In recent years, more cases are being described though now in premature infants. This is believed to be as a result of increased survival of premature babies with immature gut, as well as the use of fortified feeds used to facilitate weight gain.[3],[4],[5]

We present a case series of four patients who were managed for milk curd obstruction within 1 year at our tertiary institution. We noted that all babies who developed the condition had been treated for preexisting bowel pathology.


  Methods Top


Case notes of four patients who were diagnosed with milk curd obstruction from June 2017 until June 2018 were retrospectively analyzed. Data collected included gender, gestational age at birth, birth weight, preexisting gastrointestinal pathology, previous surgeries, feeding regimens utilized, as well as the presentation, management, and outcomes of milk curd obstruction.


  Results Top


All patients included in the study were premature. Three of the four patients were classified as extremely low birth weight (ELBW) babies [Table 1].
Table 1: Milk curd obstruction data

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Three of the four patients (all ELBW) were diagnosed with necrotizing enterocolitis (NEC) at a mean of 36 days (range: 30–41 days) before being diagnosed with milk curd obstruction. Two of them were conservatively managed by withholding feeds and administering antibiotics. The third patient worsened after initial conservative management and subsequently required operative treatment. No gross bowel necrosis was noted, but patchy ischemia was present along the colon. No bowel was resected, but an ileostomy was formed.

The fourth patient was noted to have a redundant, narrowed sigmoid colon on a contrast enema after delayed passage of meconium. They were therefore taken to theater and received a de-functioning ileostomy on day 2 of life.

All babies were started on exclusive breastfeeding regimens; however, due to the need to facilitate weight gain and growth, all received maternal breast milk (MBM) fortifiers. Two of the patients also had formula milk added or substituted into their feeding regimen at some point. The average time to development of milk curd obstruction after addition of fortifier was 32 days (range: 11–60 days).

The mean age at development of milk curd obstruction was 64 days (range: 38–103 days). All four patients presented with abdominal distention. Two presented with accompanied bilious vomiting, while two also presented with features of respiratory distress. One patient had bloody stools.

Three of the four patients required operative management. The diagnosis of milk curd obstruction was made intraoperatively in each of these cases. The first patient already had a pre-existing ileostomy after previous surgery for NEC. Approximately 15 cm of ileum proximal to the ileostomy was impacted with solid milk curds. These were able to be milked through the previously formed stoma [Figure 1]. The ileostomy was refashioned at the time of surgery. The second patient was noted to have an ileal perforation secondary to milk curd obstruction during their laparotomy. They had a small segment of bowel resected along with the formation of an ileostomy. The third patient was noted to have significant milk curd obstruction approximately 25 cm from the ileocecal valve. An enterotomy was made to remove the milk curds, a small amount of damaged bowel was resected, and an ileostomy was formed.
Figure 1: Intraoperatively expressed milk curds

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The last patient was managed conservatively. They had a preexisting ileostomy and were given gastrografin proximally via a nasogastric tube. The ileostomy was regularly stimulated and dilated with a surgical probe which encouraged the passage of the obstructing milk curds [Figure 2].
Figure 2: Milk curds expressed with the use of gastrografin and manual stimulation

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Patient 1 and Patient 4 both had identical twin siblings. Patient 1's twin was treated for NEC (conservatively managed) with no further complications. Patient 4's twin followed a healthy course with no gastrointestinal pathology.

All patients recovered well after their diagnosis and treatment of milk curd obstruction. They have all had successful elective stoma reversals with no complications. There have been no mortalities. All patients were followed up by the pediatric surgical team for a minimum of 6 months after their stoma reversals.


  Discussion Top


The history of milk curd obstruction as pathology has been an interesting one. It initially made its debut in term babies receiving cows' milk-based formulas [1],[2] and is now being recognized as a condition most commonly seen in premature babies receiving fortified breast milk.[3] All of the patients included in our series were premature babies who received fortified MBM and were thus in keeping with the reported cases in the literature. All the patients were also male, which is speculated to be a potential risk factor for developing the condition.[6]

Milk curd obstruction typically presents identically to other causes of acute intestinal obstruction. Babies may present with abdominal distention, respiratory compromise, and bilious vomiting.[1],[5] The aforementioned features were present in varying degrees in all of our patients. One patient included in the series also presented with blood-stained stools. This has been reported in one other case to date.[5] The ileum appears to be the most common location for milk curd obstruction to occur,[3],[5] which is in keeping with all four of our reported cases. Cases of obstructions at other levels within the bowel, however, have also been reported.[7],[8]

Analysis of the literature reveals that there may be an association between preexisting bowel pathology, previous surgery, and the development of milk curd obstruction. Drewett and Burge reported that three patients developed milk curd obstruction after treatment for spontaneous intestinal perforations (SIPs) in 2007 (after reviewing a case series of 17 patients with SIPs).[9] A milk curd obstruction case series published by Wagener et al. in 2009 revealed that five of the nine babies in the series underwent surgery before their diagnosis. Four of these babies received surgical intervention for gastrointestinal pathology while one had surgery for an unrelated condition.[3] A case report by Khanna et al. in 2017 also described the development of milk curd obstruction in a child who underwent spinal surgery.[10] All four patients in our series had preexisting bowel pathology, and two underwent surgical intervention for this.

A comparative analysis of three preexisting milk curd obstruction case series, along with our data, is presented in [Table 2]. The relative paucity of literature, along with discrepancies in data sets collected, makes it difficult to make quantitative statements regarding causation/risk when it comes to milk curd obstruction. The extrapolated comparative data do seem to suggest that a male predominance is likely. From the series that included data sets regarding surgical procedures' prediagnosis, it can be demonstrated that approximately 30% of the patients with milk curd obstruction had a surgical procedure before diagnosis. Our case series is the only one who definitively reports the presences of conservatively managed NEC before the diagnosis of milk curd obstruction, and as such, we cannot comment on a possible correlation between the two conditions. Overall predictions and estimations regarding mortality are unable to be extrapolated as a result of the varying time frames of patient follow-up reported. Eighty-two percent of all patients included in the series underwent surgical management for milk curd obstruction.
Table 2: Comparison of milk curd obstruction case series

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Milk curd obstruction is a diagnosis that is often only made intraoperatively, and as a result, there are no definitive guidelines for its management. Almost all cases will require operative management (as is the case for most nonresolving bowel obstructions), and evidence shows that conservative measures such as gastrografin enemas have had little success.[1],[3],[5] Three of our four cases required operative intervention. We were, however, able to relieve the obstruction in one patient with a preexisting ileostomy by utilizing proximal gastrografin administration via a nasogastric tube accompanied by manual stimulation and evacuation at the ileostomy site. This method has not been previously reported in the literature.

It was of interest to us that two patients included in our series had identical twin siblings who did not develop milk curd obstruction, despite being the same gestational age and receiving the same feeds. This may potentially suggest that there is unlikely to be a genetic correlation with or predisposition to developing milk curd obstruction. Significantly more research and analysis will need to be done to establish whether this is the case.


  Conclusions Top


Milk curd obstruction is an important cause of neonatal bowel obstruction, particularly in the premature and ELBW population. We propose that previous surgical intervention and underlying bowel pathology may serve as contributing factors to the development of milk curd obstruction. Further, data collection, investigation, and analysis are required to further establish and understand the risk factors and associations of the condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lewis CT, Dickson JA, Swain VA. Milk bolus obstruction in the neonate. Arch Dis Child 1977;52:68-71.  Back to cited text no. 1
    
2.
Cook RC, Rickham PP. Neonatal intestinal obstruction due to milk curds. J Pediatr Surg 1969;4:599-605.  Back to cited text no. 2
    
3.
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. 3
    
4.
Murase M, Miyazawa T, Taki M, Sakurai M, Miura F, Mizuno K, et al. Development of fatty acid calcium stone ileus after initiation of human milk fortifier. Pediatr Int 2013;55:114-6.  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.
Longardt AC, Loui A, Bührer C, Berns M. Milk curd obstruction in human milk-fed preterm infants. Neonatology 2019;115:211-6.  Back to cited text no. 6
    
7.
Karkiner A, Temir G, Hoşgör M, Günşar C, Karaca I. Ceacal perforation in a premature newborn infant complicating milk curd syndrome: Case report. Turk J Gastroenterol 2003;14:148-50.  Back to cited text no. 7
    
8.
Albayrak B, Horsch S, Tröbs RB, Roll C. Colonic milk curd obstruction in an extremely low birthweight infant. Arch Dis Child Fetal Neonatal Ed 2014;99:F237.  Back to cited text no. 8
    
9.
Drewett MS, Burge DM. Recurrent neonatal gastro-intestinal problems after spontaneous intestinal perforation. Pediatr Surg Int 2007;23:1081-4.  Back to cited text no. 9
    
10.
Khanna K, Khanna V, Dhua A, Bhatnagar V. Milk curd syndrome: A forgotten entity. Adv Res Gastroentero Hepatol 2017;4:3-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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