Vol. 157, No. 1 � July 2010

regimens evaluated, extensively hydrolyzed protein formulawith and without the addition of lactobacillus GG. If baselinevalues were artificially higher because of the presence ofblood, it should have affected stools from both dietary groupsequally and thus had no impact on results.

Savino et al state that we did not clarify whether patientshad anal fissures or gastroesophageal reflux. None of thepatients studied had anal fissures, and we are not sure whygastroesophageal reflux had to be ruled out in infants whoseonly symptoms were blood and mucus in the stool. Finally,Savino et al state that they found higher FC levels in breast-fed infants compared with formula-fed infants. That seemsto be in contrast with the findings of Campeotto et al,3

who reported no differences related to type of feeding.

Maria Elisabetta BaldassarreNicola Laforgia

Annamaria LaneveRoberto Grosso

Margherita FanelliCarlos Lifschitz, MD

Baylor College of MedicineChildren’s Nutrition Research Center

Houston, Texas10.1016/j.jpeds.2010.03.029

References

1. Conover WJ. In: Practical Nonparametric Statistics. 3rd ed. New York:

Wiley, 199X. p. 419.

2. Box GEP, Hunter JS, Hunter WG. Statistics for Experimenters: Design,

Innovation, and Discovery. 2nd ed. New York: Wiley; 2005.

3. Campeotto F, Kalach N, Lapillonne A, Butel MJ, Dupont C, Kapel N.

Time course of faecal calprotectin in preterm newborns during the first

month of life. Acta Paediatr 2007;96:1531-5.

4. Baldassarre ME, Laforgia N, Fanelli M, Laneve A, Grosso R, Lifschitz C.

Lactobacillus GG improves recovery in infants with blood in the stools

and presumptive allergic colitis compared with extensively hydrolyzed

formula alone. J Pediatr, in press

Clostridium perfringens and necrotizingenterocolitis

To the Editor:Necrotizing enterocolitis (NEC) continues to cause death

in a significant number of premature infants. Altered bacterialcolonization after birth is believed to represent a crucial stepin the pathogenesis of the disease.1 However, only limited hu-man data is actually available to support or refute this hypoth-esis, partially due to limitations of conventional culturetechniques.2 From this perspective, the article by Mshvildadzeet al3 published in The Journal is of utmost importance.

Considerable controversy persists regarding the involve-ment of Clostridium perfringens (CP) in NEC.4 We reviewed66 confirmed NEC cases (Bell stage II and higher) at our in-stitution between 2000 and 2009, of which 28 (42%) under-went operation and 9 (14%) died. Intraoperative cultures of

peritoneal fluids were routinely performed. CP was found inperitoneal fluid in only 3 patients (gestational age 26, 28, and35 weeks, respectively). All 3 patients who were positive forCP presented acutely with acute abdomen and radiologic ev-idence of necrotizing panenteritis and rapidly progressed toshock and lactic acidosis. In all cases, extensive bowel necrosiswas found during surgery, and all 3 infants died shortly aftersurgery because of multisystem organ failure.

In the pilot study by Mshvildadze et al3 on intestinal florawith 16S ribosomal pyrosequencing, no CP strains werefound in infants with NEC.3 In contrast, Dittmar et al5 re-ported more severe NEC gangrene and disease progressionin infants with CP-associated NEC. These findings indicatethat although CP may not be involved in most NEC cases,CP apparently has the potential to trigger a fulminant andoften lethal course. Novel microbiologic techniques identify-ing particular specimens in stool may improve early recogni-tion of infants at high risk of severe NEC, with the potentialto guide preventive and therapeutic measures.

Luregn J. Schlapbach, MDOlaf Ahrens, MD

Department of Pediatrics

Peter Klimek, MDSteffen Berger, MD

Ulf Kessler, MDDepartment of Pediatric Surgery

InselspitalUniversity of BernBern, Switzerland

10.1016/j.jpeds.2010.03.027

References

1. Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006;368:1271-83.

2. Hoy CM, Wood CM, Hawkey PM, Puntis JW. Duodenal microflora in

very-low-birth-weight neonates and relation to necrotizing enterocolitis.

J Clin Microbiol 2000;38:4539-47.

3. Mshvildadze M, Neu J, Shuster J, Theriaque D, Li N, Mai V. Intestinal mi-

crobial ecology in premature infants assessed with non–culture-based

techniques. J Pediatr 2010;156:20-5.

4. de la Cochetiere MF, Piloquet H, des Robert C, Darmaun D, Galmiche JP,

Roze JC. Early intestinal bacterial colonization and necrotizing enteroco-

litis in premature infants: the putative role of Clostridium. Pediatr Res

2004;56:366-70.

5. Dittmar E, Beyer P, Fischer D, et al. Necrotizing enterocolitis of the neo-

nate with Clostridium perfringens: diagnosis, clinical course, and role of al-

pha toxin. Eur J Pediatr 2008;167:891-5.

Intracranial cavernous hemangiomas ofinfancy

To the Editor:Azam and O’Donovan reported the case of a newborn infant

with tonic-clonic seizures. With radiological investigation, thepresence of an intracranial cavernous hemangioma was re-vealed. The infant was treated conservatively and remained

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