SUMMARY. Twenty-eight pre-term babies of low birth weight were monitored for developing microflora in throat, stomach and faeces during the first 3 weeks of life. The flora at all levels of the gastrointestinal tract differed from that of healthy breast-fed and artificially fed full-term babies. Colonisation of throat and stomach was delayed beyond 4 days of life in 87% and 60% of babies respectively. Only 10% of babies had "normal" oral flora throughout the period of study. Flora of the stomach was sparse, and resembled faecal flora. Faecal flora was established more rapidly than throat or stomach flora, and 70% of babies were colonised during the first 4 days of life. Initially Bacteroides spp. were predominant (57% babies), but Escherichia coli and other aerobic gram-negative bacilli gradually increased in frequency. Colonisation by gram-positive bacteria was slow. Clostridium spp. were present in only 10% of babies during the first 4 days of life. Most strains were transient. Colonisation with C. butyricum (30%), C. perfringens (35%) and C. dzficife (25%) was maximum after the first 2 weeks of life. Lactic-acid-producing bacteria usually appeared late in the third week of life. Parenteral feeding immediately after birth was associated with delayed colonisation by a restricted number of species. Parenteral antibiotics (penicillin or gentamicin or both) restricted colonisation with normal oral flora, the lactic-acid-producing bacteria and penicillin-sensitive clostridia, but had little effect on E. coli even when the colonising strain was sensitive to the aminoglycoside in the regimen. Systemic spread of bacteria via the blood stream was not detected in any babies.The pattern of colonisation of the enteric tract in pre-term infants in the special-care nursery studied, differs from that of healthy full-term babies; this merits consideration when the results of bacteriological tests on this vulnerable group of infants are being interpreted.

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Fecal flora of 12 children undergoing bone-marrow transplantation was monitored prospectively using comprehensive microbiological techniques. Diarrhea developed at least once in ten of the 12 children (83%), and a total of 24 episodes were recorded. Recognised gut pathogens were isolated from 11/21 (52%) diarrheal episodes where fecal specimens were obtained. Enteric pathogens identified included viral pathogens in 19% (rotaviruses, 'enteric' adenoviruses), parasites in 19% (cryptosporidium, Giardia lamblia) and cytotoxic C. difficile (14%). Excretion of clostridial species (including cytotoxin negative C. difficile, C. innocuum) occurred in 90% of diarrheal episodes when no enteric pathogen was identified. These results suggest that infection is often responsible for diarrhea associated with bone-marrow transplantation. Prophylaxis against enteric infection might reduce the morbidity and mortality associated with severe diarrhea in bone-marrow transplanted children.

An 8-year-old boy with a short gut had six episodes of metabolic acidosis and neurological dysfunction over a 1 month period. The neurological features consisted of a depressed conscious state, confusion, aggressive behaviour, slurred speech and ataxia. The organic acid profile of urine demonstrated increased amounts of lactic, 3-hydroxypropionic, 3-hydroxyisobutyric, 2-hydroxyisocaproic, phenyllactic, 4-hydroxyphenylacetic and 4-hydroxyphenyllactic acids. Of the lactic acid 99% was D-lactic acid. The anaerobic gut flora consisted almost entirely of Lactobacilli in unusually large numbers. A course of vancomycin prevented further episodes. A urinary organic acid profile may be diagnostic when a person with a short gut develops metabolic acidosis or an unusual encephalopathy and bacterial metabolites should be considered in other patients with unusual combinations of organic acids in the urine.

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