Aloe vera induced toxic colitis in a breast-feeding baby: a case report

Introduction

Aloe vera is available as both a topical and oral herbal remedy. It is used as a treatment for a broad range of conditions, such as constipation, arthritis, eczema, psoriasis, and chronic fatigue syndrome. Aloe vera potentially contains 75 active compounds, including anthraquinones, amino acids, and a number of enzymes [2]. It has been shown that anthraquinones, one of the active components of aloe vera, can cause drug induced gastrointestinal disturbances. These include nausea, vomiting, diarrhoea, and in some cases, hepatitis [3]. Anthraquinones have been isolated in breast milk and their possible effects in the breast fed infant have not been fully investigated [1, 4]. We present a case of toxic colitis in a neonate that was associated with maternal consumption of an aloe vera cordial in the previous 48 h. No similar cases have been previously described in the literature. Aloe vera is a very popular alternative medicine and is generally perceived to be relatively harmless. We believe that it is important to present this case and highlight the potential side effects that aloe vera can have for infants of breastfeeding mothers.

Case presentation

A full term baby was admitted to the neonatal unit with poor feeding on day 2 of life. Breastfeeding was subsequently established and she was discharged on day 3. She was readmitted on day 8 after being reviewed by a public health nurse in the community. She had lost 10% of her birth weight and was described as feeding poorly. On admission, fresh blood was noted in her faeces. She was breastfed and had not received any formula feeds. Over the next 2 days she developed profuse watery diarrhoea. On day 10 she was severely dehydrated and had lost 16% of her birth weight. A capillary blood gas revealed a metabolic acidosis with pH 7.09, bicarbonate 18.5, lactate 4.7, and base excess of –11.3. The infant was treated for hypovolaemic shock, initially given fluid boluses amounting to 30 mL/kg, and was also commenced on broad spectrum antibiotics, gentamicin, and teicoplanin. An abdominal X-ray displayed distension of bowel loops and bowel wall thickening consistent with colitis. Initial C-reactive protein (CRP) was normal. However, the CRP on the following day was raised at 30, but this normalised 48 h later. All parameters of the full blood count were normal. Stool samples were negative for ova, cysts, bacteria, and viruses including rotavirus. Metabolic screen including serum amino acids, urine organic acids, ammonia, and acylcarnitine profile was normal. Oral feeding was discontinued and fluid losses were replaced over 36 h. In total, she received 5 days of parenteral nutrition and intravenous antibiotics.

On closer questioning, it appeared that the infant’s mother had consumed 2 L of Aloe Vera King^® (OKF Corporation, Seoul, Korea), an aloe vera based cordial, which she had purchased in a health food shop for laxative reasons. A sample of breast milk was sent for mass spectroscopy. Aloe vera was not isolated and it was not interrogated for the presence of anthraquinones. The infant was subsequently recommenced on oral feeds. Initially, a hydrolysed lactose free infant formula was introduced followed by the reestablishment of breastfeeding. She was seen in the outpatient clinic at 2 and 4 months of age. She was thriving on breastfeeds and had no reoccurrence of the presenting symptoms.

Discussion

In this report we describe a temporal association between maternal ingestion of a significant volume of an aloe vera cordial and toxic colitis, resulting in hypovolemic shock in a breastfeeding newborn infant. This infant became severely dehydrated from explosive diarrhoea (a known physiological effect of the anthroid derivatives of aloe vera), resulting in a severe metabolic acidosis and radiological evidence of a colitis. Although an association does not prove causation, we did not find another explanation for this infant’s rapid deterioration. In addition, the infant’s colitis resolved once breastfeeding was discontinued and she remained completely well following recovery from this acute episode of shock. Also, a full sepsis screen, including stool cultures for rotavirus, and a metabolic screen were negative. Finally, this infant subsequently thrived on breastfeeding once aloe vera had been removed from the maternal diet. A sample of this mother’s breast milk expressed at the time of presentation of the infant was sent for evaluation but aloe vera was not isolated. However, the sample was not analysed for the presence of anthraquinones.

Aloe Vera King^® is advertised as a natural laxative (as a result of the presence of anthraquinones) that aids weight loss. It is widely available in health food stores across the world and is manufactured in the USA. Indeed, the manufacturer of this particular brand claims that 500 million bottles of their product have been sold. The World Health Organisation does not recommend the use of aloe vera during pregnancy [5]. However, there were no warnings for breastfeeding mothers of any potential associated hazards displayed on the Aloe Vera King^® brand consumed by the mother in this case. We believe it is important to bring the potential and serious hazards of aloe vera cordials to infants of breast-feeding mothers into the public domain.