Ch. 35 Excessive Drooling in a Newborn

Question 1

Differential dx of excessive drooling/feeding intolerance in a newborn

Answer 1

• Choanal atresia –> inability to pass NGT
• Cleft palate
• Esophageal atresia w or w/o TEF –> OGT/NGT seen curled in upper esophageal pouch on AP and lateral radiographs
• Esophageal web or ring –> usually asymptomatic until later in life, vomiting if symptomatic, circumferential partial obstruction on contrast esophagram
• Food sensitivity –> normal anatomy (usually accompnaying rash or diarrhea)
• Gastroesophageal reflux –> absence of anatomic abnormalities, frequent regurg/vomiting
• Mediastinal/tracheal compression
• Neurologic disorder –> uncoordinated peristalsis on swallow study

Question 2

What is the significant of oxygen desaturation that only occurs while feeding?

Answer 2

When a newborn has desaturations while feeding, it implies that there is a significant anatomic or functional problem with proximal alimentary tract (nasopharynx, oropharynx, esophagus, stomach)

Question 3

Associated anomalies with TEF

Answer 3

50% of children with TEFs have associated anomalies: VACTERL & CHARGE

• Vertebral –> Hypoplastic or hemivertebrae
• Anorectal –> Anal atresia/imperforate anus ** look for fistula nearby (to vagina or perineum)
• Cardiovascular –> ASD, VSD, ToF, truncus arteriosus, transposition of great vessels
• Tracheoesophageal fistula
• Esophageal atresia
• Renal –> agenesis, hypoplastic/dysplastic kidney, horseshoe kidney, ureteral obstruction, VUR
• Limb –> displaed or hypoplastic thumb, polydactyly, syndactyly, radial aplasia
• Coloboma
• Heart defect
• Atresia choanae
• Retarded growth and development
• Genital abnormality
• Ear abnormality

Associations with trisomies 18, 21, 13

Question 4

Workup:

Best initial diagnostic test

Answer 4

Chest radiograph (AP/lateral) after placement of NGT/OGT

Question 5

Mgmt:

First step in clinical mgmt?

Answer 5

If patient is exhibiting signs of respiratory compromise, endotracheal intubation and mechanical ventilation are required

Preop mgmt aimed at minimizing risk of aspiration (continuous suction of blind upper esophageal pouch and elevation of infant’s head)

- POTENTIAL GASTROTOMY

Abx for pneumonia

Question 6

Definitive treatment

Answer 6

Surgical divison of fistula tract with repair of trachea and primary anastomosis of esophagus

Question 7

Interrupted IVC

Answer 7

Very rarely, IVC drains into RA via azygous system. During typical EA/TEF repair, azygous vein is divided to allow access to TEF… divison of azygous vein in a patient with an interrupted IVC will disrupt all venous return from abdominal viscera and LE