A girl was born at 40 weeks and 2 days to a 31-year-old mother who had received routine prenatal care starting in the first trimester. This was the mother's first pregnancy; both pregnancy and delivery were uncomplicated. At birth, the child had a large, right-sided, firm-to-hard facial mass. She had normal vital signs at birth, with a heart rate of 125 bpm, respiratory rate of 44 breaths per minute, temperature of 98.2° F, Apgar score of 9 and 9 at 1 and 5 minutes, respectively, no clinical evidence of respiratory distress, and successful feeding by mouth. The tumor was consistent with infantile fibrosarcoma, and treatment for the child began at 6 weeks of age. Chemotherapy consisted of vincristine (0.05 mg/kg), dactinomycin (0.025 mg/kg), and cyclophosphamide (25 mg/kg) (VAC). Each cycle of chemotherapy was approximately 4 weeks. Throughout cycle 1 of chemotherapy, the patient's bowel regimen consisted of lactulose after vincristine for 24 hours. Lactulose was chosen because of her young age, and she had multiple soft stools daily.
Seven days after cycle 2 of chemotherapy, she was admitted for fever and abdominal distension; computed tomography of the abdomen and pelvis was consistent with diffuse pneumatosis of the colon. She was treated with antibiotics, total parenteral nutrition, and medical observation, and she was discharged after 9 days in the hospital. The patient restarted VAC therapy with slow-dose escalation of her chemotherapy throughout cycle 3. Lactulose was scheduled for 48 hours after doses of vincristine, and, by cycle 6 of chemotherapy, she had difficulty stooling without lactulose. Her parents reported that she produced 1 to 2 hard stools per day for the week after her chemotherapy treatment and required lactulose for 48 hours after vincristine and intermittently throughout the week. She did not receive any other medications, vitamins, or acupuncture to alleviate constipation.