Dr. Hiren Doshi
Director − PICU & NICU
Nanavati Super Speciality
Hospital, Mumbai

Dr. Pankaj R. Shroff
Sr. Consultant,
Paediatric Surgery Nanavati Super Speciality
Hospital, Mumbai

Dr. Suresh Birajdar
Joint Director
PICU & NICU
Consultant Paediatrician
and Neonatologist
Nanavati Super Speciality
Hospital, Mumbai

Gastrointestinal perforations in neonates is a challenging condition with associated mortality reported anywhere between 17-60%. Necrotizing Enterocolitis is the most common cause of intestinal perforation in neonates followed by spontaneous perforations and mechanical obstruction of the gut.

THE CASE

Here’s a case of an extremely low birth weight infant who had intestinal perforation on the third day post-delivery that was treated successfully. During the seventh month of pregnancy, the Gynaecologist noted a problem in the baby’s growth inside the womb. The baby was not getting enough blood supply through placenta and was experiencing utero-placental insuffi ciency. This resulted in poor growth of the baby and reversal of blood fl ow from the placenta. Both parents were counselled regarding implications of growth failure in the baby which could result in signifi cant damage including non-survival (death) of the baby in utero. After consulting with specialists, the family decided to go ahead with an early delivery.

THE PROCEDURE

The baby boy was delivered by emergency caesarian section at Nanavati Super Speciality Hospital. He weighed just 900 grams and had to be admitted to neonatal intensive care unit. After birth, he required intubation and mechanical ventilation. He was administered surfactant for lung maturity, kept nil per orally and started on intravenous fl uid with parenteral nutrition.

On the second day, the baby showed abdomen distension. X-ray revealed that he had air under diaphragm indicating intestinal perforation. The surgical team inserted a peritoneal drain that decompressed his bowel loops. He needed two surgeries in the following week to seal two perforations that had occurred in his small intestine. An ileostomy was performed for gut recovery and future feeding.




Lateral decubitus x-ray showing free air due to perforation of intestine

To rest the sick intestines, the baby was not given feeds for a week after surgery and was managed on intravenous nutrition of glucose, proteins and lipids administered via PICC (peripherally inserted central venous catheter). Very little amount of breast milk feeds (1 ml every 4 hours) was introduced in the third week through an orogastric feeding tube. Gradually his feeds were increased and eventually intravenous nutrition was stopped when he was 33 days old. The next two months continued with breast-milk feeding and it’s fortifi cation with calcium, vitamin D, iron and multiple vitamins and minerals to catch up with the poor growth. Eventually, at the end of the fourth month, the infant had doubled his birth weight to 1.8 kgs. He underwent his third surgery to successfully re-anastomosis his intestines and close the ileostomy. The premature lungs of the baby, received CPAP (pressurized mixture of air and oxygen through a nasal tubing) support and oxygen for the fi rst seven weeks. The baby also received laser therapy to treat Retinopathy a not so common complication of prematurity

THE RESULT

The baby made a healthy recovery and weighed around 2 kgs during discharge. The parents were advised for follow-up visits with his Paediatrician and in the fi rst follow-up, his screening tests for hearing, vision and brain came in normal.

DISCUSSION

Even in seemingly healthy pregnancy, regular visits to the Obstetrician and serial ultrasound are recommended. Although rare, intestinal perforations can occur in babies who have extremely low birth weight with in-utero deprivation of nutrition due to placental issues. It needs very high index of clinical suspicion with presence of signs such as abdominal distension, bilious aspirates from feeding tube and failure to pass meconium. On routine frontal fi lm of x-ray of abdomen, the perforation may not be picked up. A lateral decubitus fi lm is useful in this situation as the free gas can be picked up in this view more easily. Perforation of intestines can be fatal unless clinically suspected, diagnosed immediately and treated promptly. Occasionally, a baby could have multiple perforations that need to be diagnosed with imaging studies and treated during Laparotomy.

Providing nutrition including proteins and fats through intravenous route is essential in the recovery of these babies while their gut is recuperating from the damage. Breast milk is the most ideal diet for these babies once they are started on feeds.