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Colorado Springs, CO
ABSTRACT
PURPOSE OF THE STUDY.: To determine the prevalence of allergic colitis (AC) in a cohort of healthy infants with rectal bleeding. A secondary purpose was to determine if bleeding would resolve in untreated infants with rectal bleeding without biopsy-proven AC.
STUDY POPULATION.: There were 22 infants 
6 months of age with rectal bleeding recruited from the referral area of Cincinnati Children’s Hospital Medical Center (Cincinnati, OH). All subjects had a negative history of bleeding disorders, negative stool cultures, positive hemoccult, and a negative history and physical examination for signs of infection, Hirschsprung disease, and inflammatory bowel disease.
METHODS.: AC was defined histologically as colonic mucosa with 
6 eosinophils per high-power field and/or eosinophils in the colonic crypts or muscularis mucosae. Formula or maternal diet was changed only for infants with histologic findings of AC. Formula-fed infants were switched to an extensively hydrolyzed formula and were rebiopsied at 3 weeks. If the biopsy was normal, they were continued on the formula and managed clinically. Those with continued histologic evidence of colitis were changed to an amino acid–based formula and rebiopsied at 6 weeks. Breastfed infants continued breastfeeding while mothers followed a milk-protein–free diet. Those with resolution of bleeding and normal biopsies at 3 weeks continued with breastfeeding and a restricted maternal diet. Those with persistent histologic evidence of colitis were rebiopsied at 6 weeks with no further dietary change. Those with persistent bleeding were changed to hydrolysate and rebiopsied at 6 weeks. Those with persistent bleeding and histologic evidence of AC at 6 weeks were changed to an amino acid–based formula.
RESULTS.: Of 22 subjects, 14 (63.6%) had histologic evidence of AC. Five had normal biopsies and 3 had nonspecific colitis. Seven of the 14 with AC were formula fed. Six of the 7 had resolution of bleeding, on average, in 1.8 weeks (range: 1–5 weeks). One of the 7 was changed to an amino acid formula at 3 weeks and had resolution of bleeding at 5 weeks. The remainder of the 14 were breastfed. Six were followed to completion of the study. One had a delayed diagnoses because of development of worsening rectal bleeding and an abnormal biopsy at week 3 despite a normal biopsy at the onset of the study. The infant failed to improve with hydrolyzed formula but had resolution of bleeding by week 8 after initiation of an amino acid formula. Of the remaining 5, 2 had normal histology at week 3 with maternal elimination of cow’s milk. Two had improvement by week 3, and 1 had no change. The average time for resolution in the breastfed group was 5.6 weeks (range: 2–8 weeks). For the 5 infants without histologic evidence of colitis, the average time for resolution of bleeding was 3.25 weeks. In those with nonspecific colitis, 2 had resolution by week 6, and the third was ultimately diagnosed with inflammatory bowel disease.
CONCLUSIONS.: A significant proportion of infants with rectal bleeding may not have AC and may undergo unnecessary, expensive formula or maternal diet changes that may discourage breastfeeding.
REVIEWER COMMENTS.: This small study provides important insights about the prevalence and natural course of proctocolitis. A much larger prospective placebo-controlled study that compares treatment versus no treatment would be very helpful.
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