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Meconium Ileus in Preterm Infants
Meconium Obstruction in the Very Low Birth Weight Premature Infant. Sanjuanita Garza-Cox, MD, et al. PEDIATRICS (July 2004); 114:285-290.
Meconium obstruction of prematurity is a distinct clinical condition that occurs in very low birth weight infants, predisposing them to intestinal perforation and a prolonged hospitalization if not diagnosed and treated promptly.
Objective: We report a series of 21 infants, including 2 detailed case reports, whose clinical course is indicative of meconium obstruction of prematurity. Specific risk factors are identified along with descriptions of clinical and radiologic findings, disease course, treatment, and outcome. Meconium obstruction of prematurity was more common in infants with a maternal history of pregnancy-induced or chronic hypertension, suggesting the possibility of decreased intestinal perfusion prenatally. Inspissated meconium was located most frequently in the distal ileum, making this disease process difficult to treat. Gastrografin enemas were safe, diagnostic, and therapeutic. Delay in diagnosis and treatment was associated with perforation and delay in institution of enteral feeds.
Methods: The medical records of premature infants with a diagnosis of meconium plug syndrome or meconium ileus as well as those who underwent a laparotomy or ileostomy during the 7-year period from January 1995 to July 2002 delineate several profound changes were reviewed. Only those preterm infants weighing <2000 g at birth were included. Patients were identified by searching the database of infants admitted to the neonatal intensive care unit at the University of Texas Medical Branch in Galveston, Texas.
Medical records were reviewed for demographic data, prenatal risk factors, feeding and stooling patterns, radiographic findings, interventions, complications, and time of resolution. Infants with diagnoses of gastroschisis, intestinal atresia/strictures, Hirschsprung’s disease, and malrotation were not included. Infants with either spontaneous intestinal perforation or necrotizing enterocolitis (NEC) (diagnosed by radiographic/clinical evidence or gross specimen or histologic evaluation) who did not have a history of either delay in passage of meconium or inspissated meconium on pathologic evaluation were eliminated from the study. For the comparison of prenatal complications, a control group of infants was matched for the study group. The infant born immediately before and after the study infant weighing ±100 g of the birth weight of the study infant was included (n = 42). Infants were excluded from the control group if they had multiple congenital anomalies, intestinal perforation for any reason, or NEC. Logistic regression was used to examine the association of maternal complications and meconium obstruction. The study protocol was approved by the Institutional Review Board for Human Subjects at the University of Texas Medical Branch.
Conclusions: We report a group of 21 preterm infants with meconium obstruction of prematurity. These very low birth weight infants had initial spontaneous passage of meconium followed by signs and symptoms of low intestinal obstruction. They were more likely to have prenatal histories of maternal hypertension. Inspissated meconium in the distal ileum was noted in 57% of the infants. In infants who have the classic findings of meconium obstruction of prematurity, such meconium in the ileum is not associated with cystic fibrosis. Gastrografin enemas proved to be safe, diagnostic, and the best therapeutic method in our patient population. However, one third of infants required surgical management because of spontaneous intestinal perforation or worsening obstructive symptoms secondary to inspissated meconium in the distal ileum. Delay in diagnosis was associated with perforation and postponement in attaining adequate enteral nutrition. Because meconium plug syndrome is becoming a more prevalent and important diagnosis, prompt recognition of this disease and its risk factors with early and aggressive medical management is essential to prevent the need for surgical intervention.
Comment:
This article points out that meconium obstruction of prematurity must be
considered in the very low birth weight infant who presents with intestinal
obstruction, especially if maternal antecedents include PIH or chronic
hypertension. Given that air mixed with inspissated meconium may have the
radiographic appearance of bubbly pneumatosis, it is not inconceivable that
some of us have erroneously invoked NEC as the cause of intestinal
perforation. As the authors point out, awareness of this diagnostic
possibility may allow appropriate intervention (e.g., gastrografin enema)
before perforation might occur. MH
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