Transcription:
Taboo Topics: Bowel Issues in Newborns

Bill Klaproth (Host): Newborn bowel problems, those involving the small and large intestine as well as anorectal concerns aren’t a popular topic of conversation. But how common are these conditions in newborns? Let’s find out with Dr. Tim Jancelewicz, a pediatric surgeon at Le Bonheur Children’s Hospital. This is the Peds Pod by Le Bonheur Children’s Hospital. I’m Bill Klaproth. So, Dr. Jancelewicz, how common are newborn bowel problems?

Tim Jancelewicz. MD (Guest): Well if we are not talking about the esophagus and the stomach, we are just talking about the intestine and the colon and the rectum; it’s about one in a thousand to one in five thousand births depending on which condition you are talking about. So, in Shelby County, with 13,000 births per year or so; we’d expect about or at least ten cases of something like necrotizing enterocolitis which is one in a thousand births or five or six cases per year of rarer disease like Hirschsprung’s Disease which is one a 5000 births.

So, taken together, although these are individually quite rare; birth defects in general occur in two to four percent of births so one in twenty births up to one in fifty births. And so, all together, things are pretty common.

Host: Wow, it sounds more common than expected. So, what are some of the most common bowel abdominal conditions that you encounter in newborns?

Dr. Jancelewicz: Well in premature infants, necrotizing enterocolitis or NEC is probably the most common problem. That’s about 10% of premature infants may be affected by that. But when you are talking about a missing part of the intestine like an atresia when you are missing a piece of the intestine, that’s about one in two thousand births and I’d say that’s probably the most common followed by something called gastroschisis where there’s a hole in the abdominal wall and you are born with your intestines hanging out; that’s about a one in two thousand and then less common diseases like Hirschsprung’s Disease is about one in 5000 and then omphalocele where you have a big hernia at your belly button, a big hole at your belly button, that’s about one in 5000. And then a more rare disease but a very severe one is when your intestines are not rotated correctly, or they are not fixed inside your abdomen correctly. And that’s called malrotation. That’s probably pretty common but when the intestines twist on themselves and cause a big problem, that’s about one in 6000 births.

Host: Oh, my goodness. So, how do you discover that a baby has bowel issues?

Dr. Jancelewicz: Well if it’s a developmental problem that happens before birth, such as an atresia when you are missing part of your intestine; you might notice a dilated intestine, big intestine on your prenatal ultrasound. Or you may have an abnormal amount of amniotic fluid and you may actually not pick any of this up prenatally. In which case, you will have a postnatal diagnosis after the baby is born. You may have symptoms that lead to the diagnosis. Or you may have a delayed diagnosis much later after birth.

Host: Okay. So, let’s talk about those symptoms then. What are the signs that my baby may have a surgical intestinal issue?

Dr. Jancelewicz: Well they may see that dilated intestine on prenatal ultrasound. They may see abnormal levels of amniotic fluid. There could be other concerning findings like delayed growth or other issues with the baby. But some things are more obvious after birth like for example an imperforate anus or an anorectal malformation where the baby is born without any opening where an anus should be or an abnormally positioned anus and then there may not be an obvious sign right away, but a baby may not be able to eat, may throw up and it may fail to poop during the first day of life. So, failure to pass meconium as we say.

There are other signs that could be an emergency such as bilious or green vomiting and that to me is the most concerning because when you see green vomiting in a newborn, that suggests the possibility that the intestines are twisted which is a surgical emergency.

Host: So, let’s take each one of these one by one to understand them better. Let’s start with the anorectal malformation formally known as an imperforate anus.

Dr. Jancelewicz: The anorectal malformation is basically a form of atresia or just failure of development of the normal anus. And so, what happens is the opening either is in the wrong spot, too far forward typically or it connects to the urogenital tract. And so in that case, what we do is we first have to know that there’s a problem and then we have to do a study to check to see how far the rectum is from the actual surface of the butt or where the position of the opening is. And if it’s a low lesion as we call it, if it’s easy to get to; we might do an operation right soon after birth to move the anus to the correct position. Or if it’s a more complicated situation, where the rectum connects to the bladder or to the urethra in a boy or to the vagina in a girl; we may have to do a staged operation where we put in a temporary ostomy in the newborn and then wait a few months for the baby to get bigger and then move that anus into the right spot. It can be a complex operation.

Host: Yeah, it sounds like it. Okay so then let’s turn to the necrotizing enterocolitis. Tell us about that and how you repair that.

Dr. Jancelewicz: Well unlike an atresia or an anorectal malformation, this is an acquired disease that occurs typically in premature infants and 90% of the time, it’s in a preemie. And the smaller you are, the more likely it is. It occurs in about 10% of extremely low birth weight infants which is less than 1000 grams at birth. And what it is, is the intestine is just too immature to tolerate a bacterial infection inside the intestine and the blood flow is cut off to the intestine and you may have an extensive loss of intestine. And you may have a perforation or a hole in the intestine.

If that happens, then you may require emergency surgery in a tiny baby. But typically, we are able to treat this with antibiotics and bowel rest. So, the babies will not get fed and we feed them through their veins with parenteral nutrition so that they can get bigger and then hopefully get better from that infection and not require surgery.

Host: Right. Okay and then you also mentioned Hirschsprung’s Disease. How do you treat this condition?

Dr. Jancelewicz: Ideally, you would know that the baby has Hirschsprung’s Disease early on but sometimes we don’t know it until kids are older and that can be a big problem because what Hirschsprung’s Disease is, is missing ganglion cells or nerves in the rectum which means that the rectum is not able to make the poop go through and come out and so babies and children can be very constipated from Hirschsprung’s Disease.

And the treatment for it is to remove the part of the colon and rectum that doesn’t have nerves in it and pull down the part that does have nerves in it and make a new opening where the anus is. And that requires a pull through procedure it’s called which is typically done at a few months of life or sometimes soon after birth if the length of intestine that’s involved is not very long.

Host: So, Doc with these repairs, does baby generally grow up normally then and not have any ill side effects from these procedures?

Dr. Jancelewicz: Well, sometimes some of these congenital anomalies are associated with other problems like a heart defect or a chromosomal problem or other diseases. And so one of the things we have to do when a baby is born with something like this, is look for other issues and make sure there is nothing else going on. But in a baby with an isolated condition, typically, they can expect to have a normal life. They may have issues with constipation in the long term if they have Hirschsprung’s Disease. And then for the anorectal malformation, may not have normal function of this intercomplex which is the muscle that holds poop in and so they may actually have accidents during the school days for example and it can be quite a problem for some of these kids. And so, it can be a bit of a process to learn how to poop normally in some of these children.

Host: Wow, you just mentioned some of these kids may have accidents during school days. So, how do we take away the stigma and get children the help that they need?

Dr. Jancelewicz: It can be difficult in some situations for kids to have normal stool patterns, but we do have some techniques available and children as they get older, can learn well how to take care of themselves and the parents can help them in that process. But it can be difficult. Fortunately, in a lot of babies, things like ostomies and abnormal situations are temporary and we fix them with surgery and hopefully in most cases, children go on to have normal lives.

Host: Well that’s really good news. And I’m happy to hear that. So, lastly, can you walk us through a common case you might encounter?

Dr. Jancelewicz: Sure. A typical situation might be a baby is born who had a normal prenatal course, didn’t have anything on ultrasound and mom is expecting and dad is expecting to have a normal child. And they may have a baby who for some reason is not able to eat. They are feeding the baby and the baby throws up or the baby doesn’t poop. And they are very concerned by that naturally. And so they take them to the doctor, or it’s noticed soon after birth and they get an x-ray and they might see big dilated loops of intestine or they may see that air doesn’t get all the way through to the rectum on the x-ray.

And then we may get another study to see what’s going on like a contrast study to look to see on x-ray if there’s blind ending part of the intestine, an atresia might be happening, a missing part of the intestine. And then we may take that baby to the operating room given those findings and do a little operation where we make an incision in the belly and look and see what’s going on and we may find a piece of intestine missing. It may be an intestinal atresia and then we might sew the two ends of the intestine together that normally should be connecting.

And that operation would be pretty quick, and the baby might take about a few days to start eating but then within about ten to 21 days of life or so; that baby would go home and have a normal life from an intestinal atresia.

Host: Well this has really been interesting. Thank you Dr. Jancelewicz and to learn more just visit www.lebonheur.org/podcast, that’s www.lebonheur.org/podcast. And be sure to subscribe to the Peds Pod in Apple Podcasts, Google Play or wherever you listen to your podcasts. You can also check out www.lebonheur.org/podcast to view our full podcast library. And if you found this podcast helpful, please share it on your social channels. This is the Ped’s Pod by Le Bonheur Children’s Hospital. I’m Bill Klaproth. Thanks for listening.