Meconium Plug Research Articles

Etiology and Treatment Outcome of Neona tal Intestinal Obstruction in a Tertiary Hospital

A prospective study was conducted on 54 cases of neonatal intestinal obstruction, admitted in Paediatric surgery department of Rajshahi Medical College Hospital during the period from January 2008 to December 2008, a period of 12 months. The objective of the study was to find out etiological aspect and outcome of admitted patient with neonatal intestinal obstruction. The patient constituted 33.7% of total neonatal admission in Paediatric surgery department during the study period. The male: female ratio was 1.4:1 with age ranging from 1 to 28 days. Birth weight of most of the patients was above 2 kg. Most of the patients came from poor and average family. Patients from poor family are slightly ahead. Plain x-ray abdomen was done in all cases in our study. Contrast radiography performed in selected cases. Ultrasound scan done to in selective case to rule out IHPS. No rectal biopsy was taken in case of suspected Hirschsprung's disease. The causes of neonatal intestinal obstruction were in order of frequency-Hirschsprung's disease (45.2%), Intestinal atresia (24.5%), malrotation (9.4%), bands & adhesion (5.6%), meconium ileus (5.6%), volvulus neonatarum (5.6%), meconium plug syndrome (1.8%), unknown (3.7%). 50 patients were treated operatively. 28.3% cases developed complications. Most of the complications were related to colostomy and sepsis. Overall mortality was 20.8%. Mortality was maximum in intestinal atresia. Every patient was advised to come for follow up at the time of discharge but most of the people did not report. In the study only 17 (32.1%) patient came for follow up as per advice.TAJ 2009; 22(1): 198-203

QS172. ‘Pulling the Plug’ - Management of Meconium Plug Syndrome in Neonates

QS172. ‘Pulling the Plug’ - Management of Meconium Plug Syndrome in Neonates

Current significance of meconium plug syndrome

BackgroundThe significance of meconium plug syndrome is dependent on the underlying diagnosis. The incidence of pathologic finding, particularly Hirschsprung's disease, contributing to the presence of these plugs, has been debated. However, there are little recent data in the literature. Therefore, we reviewed our experience with meconium plugs as a cause of abdominal distension to evaluate the associated conditions and incidence of Hirschsprung's disease. MethodsWe reviewed the records of newborns with meconium plugs found in the distal colon on contrast enema from 1994 to 2007. Demographics, radiologic findings, histologic findings, operative findings, and clinical courses were reviewed. ResultsDuring the study period, 77 patients were identified. Mean gestational age was 37.4 weeks and birth weight, 2977 g. Hirschsprung's disease was found in 10 patients (13%). One had ultrashort segment disease and another had total colonic aganglionosis. Maternal diabetes was identified in 6 patients. No patients were diagnosed with cystic fibrosis, meconium ileus, malrotation, or intestinal atresia. ConclusionMeconium plugs found on contrast enema are associated with a 13% incidence of Hirschsprung's disease in our experience. Although all patients with plugs and persistent abnormal stooling patterns should prompt a rectal biopsy and genetic probe, the incidence of Hirschsprung's and cystic fibrosis may not be as high as previously reported.

Progression of white matter hyperintensities in elderly individuals over 3 years

The aims of this study were to examine white matter hyperintensities (WMHs) in the brains of elderly individuals, the rate of progression, the anatomic regions most vulnerable, and the predictors of change. We examined 51 healthy volunteers (mean age 71 years) with T2-weighted brain MRI on the same scanner 3 years apart. WMH volumes were determined by an automated method, and the anatomic location of change was determined for both deep WMHs (DWMHs) and periventricular WMHs (PVWMHs). The total brain WMH volume increased by 39.6%, i.e., 13.2% per year, with the change in DWMH being 43.8% and 29.7% in PVWMH. The increase was significant in all regions except the occipital lobe and cerebellum. Age, sex, and cerebrovascular risk factors were not significant predictors of WMH progression. The main predictor of progression was baseline level of WMH. The number of WMH lesions increased by a mean of 1.78, and the progression was mainly accounted for by an increase in very large (>16 mm) lesions. Eight subjects showed a slight decrease in WMH. White matter hyperintensities are progressive in most elderly individuals with an increasing rate of progression as the burden of lesions increases. The rate of progression is greater in deep white matter and in the anterior brain regions. Risk factors for progression are not well understood, and genetic and other environmental factors must be examined. Quantitation of white matter hyperintensities may serve as a surrogate marker of the progression of small vessel disease.

GOLDBERG-SHPRINTZEN SYNDROME DUE TO A HOMOZYGOUS DELETION IN KIAA1279: CLINICAL FINDINGS AND PRENATAL DIAGNOSIS IN AN AT-RISK FAMILY.

Goldberg-Shprintzen syndrome (GOSHS) is a rare autosomal recessive disorder characterized by microcephaly with polymicrogyria, mental retardation, Hirschprung9s disease, and distinctive dysmorphic features, as yet incompletely delineated. In 2005 Brooks demonstrated by homozygosity mapping a novel locus at 10q21.3-q22.1 and found homozygous nonsense mutations in KIAA1279 at 10q22.1 encoding a highly conserved protein expressed in the central and peripheral nervous system (Am J Hum Genet 77:120-126). We report a consanguineous Pakistani family with GOSHS. Their first male child had a VSD, “meconium plug syndrome,” microcephaly, and severe feeding problems. He developed intractable diarrhea in Pakistan and died at 3 months of age, without autopsy. The second child had a generous cisterna magna noted on prenatal ultrasonography. At birth her head circumference was

Effect of perinatal factors on time of first stool passage in preterm newborns: An open, prospective study

Background: Delayed passage of first stool by a newborn after birth might be an initial sign of clinical problems, such as meconium ileus, meconium plug syndrome, and intestinal atresia. Successful treatment of these conditions depends on early diagnosis, so it is imperative to note the time of first stool passage. Objective: The aim of this study was to assess the timing of first stool passage by preterm newborns in relation to antenatal exposure to magnesium sulfate (MgSO 4) and a glucocorticoid (betamethasone) and to other perinatal factors, such as gestational age, respiratory distress syndrome (RDS), and time of first enteral feeding. Methods: The subjects in this prospective, open study were preterm newbornswho were born before 37 weeks' gestation and admitted to the neonatal intensive care units of Baskent University, Adana Teaching and Research Center, and Inonu University, Turgut Ozal Medical Center, between June 2003 and August 2004. Effects of antenatal exposure to MgSO 4 and glucocorticoid on the timing of first stool passage were assessed by comparing findings in exposed newborns to findings in an equal-sized group of gestational-age-matched subjects, derived from the study cohort, who were not exposed. Relationships between time of first stool passage and both gestational age and time of first enteral feeding were assessed. Results: Two hundred premature newborns (112 males, 88 females) were included in the study. The median age at the time of first stool passage was 16 hours, and 187 (93.5%) passed their first stool by 72 hours after birth. Delayed passage of first stool was noted in 33 (16.5%) newborns. One hundred sixty-eight (84.0%) newborns passed stool before enteral feeding was started. Gestational age and time to first enteral feeding were both significantly correlated with time of first stool passage (gestational age: r = −0.259, P < 0.001; first enteral feeding: r = 0.168, P = 0.017). Time of first stool passage was significantly later in 46 newborns with RDS than in 46 gestation al-age-matched newborns without RDS (mean [SD], 44.7 [39.7] vs 20.5 [18.4] hours, respectively; P < 0.05). The newborns whose mothers had received MgSO 4 for tocolysis passed their first stool significantly later than gestational-age-matched controls (mean [SD], 26.5 [26.9] vs 11.3 [12.1] hours, respectively; P < 0.05). Antenatal exposure to betamethasone was not significantly correlated with timing of first stool passage. Conclusions: The results suggest that delayed passage of first stool in thesepreterm newborns was associated with gestational immaturity, delayed first enteral feeding, and RDS. Antenatal maternal exposure to MgSO 4 was associated with later first stool passage in these preterm newborns, whereas antenatal exposure to betamethasone was not.

Treatment of intestinal perforation in extremely low‐birthweight infants

The mortality of intestinal perforation in extremely low-birthweight infants (ELBWI) is high. It still remains to be determined whether peritoneal drainage is a definitive treatment instead of laparotomy. The authors used bedside peritoneal drainage (BSPD) as the diagnostic procedure, and exchange transfusion (ET) as the preparatory procedure for invasive stress of laparotomy. The treatment protocol is composed primarily of laparotomy combined with BSPD and ET. ELBWI who developed intestinal perforation during hospitalization between 1993 and 2000 were treated according to the aforementioned protocol. Their medical records were examined retrospectively. Eight ELBWI were identified. The subjects' birthweights ranged from 553 to 892 g and the gestational age ranged from 23 to 26 weeks. The subjects consisted of five cases with idiopathic intestinal perforation, two cases with necrotizing enterocolitis, and one case with meconium plug syndrome. Laparotomy was performed in all cases, and BSPD was performed in seven cases. Intestinal perforation was definitively diagnosed by X-ray only in three cases, while by stool-like drainage in BSPD in the other five cases. Seven (87.5%) cases survived. In this limited experience, the treatment mainly composed of laparotomy combined with BSPD and ET appeared beneficial.

Poor Feeding and Emesis in a 1-day-old Male

A 1-day-old term male infant presents with poor feeding and emesis. ### Prenatal History: ### Birth History: ### Presentation: Complete blood count, blood culture, and cerebrospinal fluid studies …

Meconium obstruction in extremely low-birth-weight neonates: guidelines for diagnosis and management

Background Guidelines for diagnosis and therapy of meconium obstruction in extremely low birth weight neonates are still not well established. Methods All low-birth-weight infants presenting with meconium obstruction over a 5-year period were reviewed retrospectively. Patients with meconium plug syndrome or cystic fibrosis were excluded. Results Seven patients were identified. Average birth weight and gestational age were 874 g and 27.7 weeks, respectively. All were products of high-risk pregnancies, and 6 (86%) were delivered by cesarian section. All patients presented with distended abdomens without peritonitis. Abdominal films showed multiple distended intestinal loops without air-fluid levels in all cases. Three patients (43%) had contrast enemas, all showing microcolon. Nonoperative therapy, consisting of rectal irrigations and N-acetylcysteine per orogastric tube, succeeded in 3 patients who were obstructed for less than 10 days and failed in 1 patient obstructed for 12 days. Four patients, all obstructed for more than 10 days, underwent enterotomy and lavage (2), bowel resection and ileostomy (1), and initial peritoneal drainage for perforation followed by bowel resection (1). All patients survived with intact bowel function. Conclusions Extremely low-birth-weight infants with meconium obstruction can be diagnosed based on their typical clinical and plain radiographic characteristics, without need for a contrast enema. Nonoperative treatment is successful early in the course of the obstruction. In the absence of an intestinal complication, simple enterotomy and meconium evacuation effectively treats long-standing obstruction.

Meconium plug obstruction.

We reviewed the final diagnosis and incidence of bowel pathology in neonates presenting with large bowel obstruction that was relieved by the passage of meconium plugs. A retrospective case-note review was undertaken of all patients with a discharge diagnosis of meconium plug syndrome (MPS), meconium ileus (MI), Hirschsprung's disease (HD), or small left colon syndrome (SLCS) from January 1996 to April 2002. Of 21 patients with meconium plug obstruction, eight (38%) had HD, nine had MPS, four had SLCS, and none had MI. However, there was considerable clinical and radiological overlap between MPS and SLCS, suggesting that these terms are imprecise. We found a much higher incidence of HD in babies presenting with meconium plug obstruction than has previously been reported. Overlap between MPS and SLCS suggests that these are not specific diagnoses and that current terminology needs to be changed. All babies with meconium plug obstruction should have HD and cystic fibrosis (CF) excluded.

Sonography-guided Gastrografin Enema for Meconium Plug Syndrome in Premature Newborns: Preliminary Results

Purpose: To evaluate the usefulness of sonography-guided Gastrografin enema for the diagnosis and treatment of meconium plug syndrome in premature newborns in a neonatal intensive care unit (NICU). Materials and Methods: Fifteen premature newborns underwent 23 sonography-guided Gastrografin enemas on the 8th day of life on average (range: 3 days-21 days). The gestational age and birth weight (meanstandard deviation) of the patients were 29 2 weeks and 999148 g, respectively. The diagnosis of meconium plug syndrome was based on relevant clinical and radiological findings. Diluted Gastrografin (1:3, 17-45 ml) was administered through a rectal tube under the guidance of sonography until it reached to the cecum. Thereafter, immediate post-procedure and delayed portable abdominal radiographs were taken. All the procedures were done within the NICU. We reviewed the dates of meconium evacuation and the first feeding after the last enema from the clinical data. Radiologically, the timing of the radiographic improvement after the last enema was checked. In cases of distended distal ileum with meconium on preenema sonography, follow-up sonography was performed to determine the interval change after gastrografin enema. Results: None of the sonography-guided Gastrografin enemas performed within the NICU caused procedure-related complications. Meconium was evacuated within one day in all patients. In 14 patients, on average, feeding was started on the 7th day and radiographic improvement was observed on the 3rd day. Four of the five patients showing a distended distal ileum with meconium revealed a decrease in ileal distension on follow-up sonography. On the other hand, the other patient, who did not show such a decrease on follow-up sonography, was found to have ileal stenosis during subsequent surgery. Conclusion: Sonography-guided Gastrografin enema is a safe and effective bedside procedure, when performed in the NICU for the diagnosis and treatment of meconium plug syndrome.

Intestinal obstruction in neonatal/pediatric surgery

Intestinal obstruction in the newborn infant and older child may be due to a variety of conditions, including atresia and stenosis, annular pancreas, malrotation, duplication cyst, meconium ileus, meconium plug syndrome and neonatal small left colon syndrome, Hirschsprung’s disease, neoplasia, trauma, and other rarer causes. The mode of presentation can be acute or more chronic with systemic upset due to shock. Neonates, more so than older children, with unrecognized intestinal obstruction deteriorate rapidly, show an increase of associated morbidity and mortality and appropriate surgical treatment becomes more hazardous. Early diagnosis depends largely on the prompt detection of obstructive manifestations by the clinician and the subsequent accurate interpretation of radiographic findings and other investigations, leading to definitive treatment, which should always be preceded by appropriate resuscitation/preparation of the infant/child. Management of intestinal obstruction will almost always be surgical, apart from some notable exceptions and all are discussed in more detail. With the advent of pediatric and neonatal intensive care and multidisciplinary care, the morbidity and mortality of cases of intestinal obstruction reported in current series is generally extremely low and mainly determined by the coexistence of other major congenital anomalies (eg, cardiac), delays in diagnosis and treatment or coexisting medical conditions. Newer treatments and future developments may reduce the residual mortality in such cases as ultrashort-bowel syndrome.

A Case Series of Gastrointestinal Abnormalities in Fetuses with Echogenic Bowel Detected During the Antenatal Period

Objective: The objective was to evaluate the incidence of gastrointestinal abnormalities amongst those fetuses with antenatally diagnosed echogenic bowel (EB). Materials and Methods: A retrospective review of all cases delivered from April 2002 to March 2003 with antenatally diagnosed EB was conducted. This was defined as bowel that appeared as echogenic as (if not greater than) the iliac bone on a real-time image. The postnatal outcomes with regard to gastrointestinal abnormalities, till their discharge, were noted. Results: Of the 13,941 patients delivered, there were 70 cases with antenatally diagnosed EB, giving an incidence of 70/13,941 or 0.50%. Of these, 6 defaulted follow-up and 1 had a mid-trimester termination of pregnancy at 21 weeks’ gestation for social reasons. Of the remaining 63 cases with EB, 2 were stillbirths at 31 weeks and 35 weeks of gestation, respectively. Three fetuses (3/63 or 4.76%) were diagnosed with gastrointestinal abnormalities. Meconium plug syndrome was diagnosed postnatally in 2 cases, of which, 1 resolved with conservative management while the other required an emergency laparotomy. Intestinal atresia was diagnosed in the postmortem of one of the stillbirths. There was evidence of intrauterine growth retardation (IUGR) in both the stillbirth and the fetus that had required laparotomy. None of the 3 fetuses exhibited clinical features of aneuploidy. Conclusion: As the quoted background risk for gastrointestinal pathology is 0.23%, an increased incidence (4.76%) is observed in those fetuses found to have antenatal EB. It is possible that the presence of IUGR is associated with a worse prognosis. Further prospective studies are needed to verify this association.

The impact of cystic fibrosis on neonatal intestinal obstruction: the need for prenatal/neonatal screening.

To determine the incidence of cystic fibrosis (CF) in neonates with intestinal obstruction (NIO) secondary to meconium ileus (MI), jejunoileal atresia (JA), meconium plug syndrome (MPS), volvulus (V), and meconium peritonitis (MP) and analyze the correlation of ultrasonographic (US) signs with CF in NIO with a prenatal diagnosis of intestinal anomaly, a prospective analysis of different types of NIO from 1990 to 1998 was undertaken. Immunoreactive trypsin measurement, genetic studies, and sweat tests were performed to confirm or rule out CF. Cases with prenatal diagnosis were analyzed for gestational age, dilated bowel, ascites, hyperechoic bowel, and calcifications. Of 80 neonates, 19 (24%) had CF: 2/33 (6%) JA, 6/14 (43%) MPS, 1/14 (7.1%) MP, 10/10 (100%) MI, and 0/9 V. Thirty (37.5%) had a prenatal diagnosis of an intestinal anomaly. The overall incidence of CF in NIO with a prenatal diagnosis of intestinal anomaly was 4/30 (13%), or 333 times the estimated risk of CF in the general population. A hyperechoic pattern with dilated bowel was associated with higher specificity for CF: 3/3 cases (100%), followed by hyperechoic bowel with ascites: 3/4 cases (75%). All babies with any type of NIO should thus be screened for CF. Prenatal screening for CF should be indicated in all pregnancies with US patterns of specific intestinal disorders.

Bilious vomiting in the newborn: How often is it pathologic?

Background/Purpose: Intestinal obstruction is one of the most common reasons for admission to a neonatal surgical unit and frequently is manifest by bilious vomiting. Not all cases of neonatal bilious vomiting are caused by intestinal obstruction. This study aimed to investigate the outcome of neonates with bilious vomiting. Methods: A prospective audit was undertaken of all neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (1998 to 2000). Infants with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnoses were recorded. Subsequent clinical progress was ascertained by out-patient review or telephone interview. Results: Sixty-three consecutive neonates (35 boys, 28 girls) were identified with a median gestational age of 40 (range 31 to 42) weeks and median birth weight of 3.5 kg (range 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hr to 28 days). A surgical cause of bilious vomiting was identified in 24 (38%): Hirschsprung's disease (n = 9), small bowel atresia (n = 5), intestinal malrotation (n = 4), meconium ileus (n = 3), meconium plug (n = 1), colonic atresia (n = 1), and milk inspissation (n = 1). Nineteen of these had both abdominal signs and an abnormal plain abdominal radiograph, and 4 had an abnormal abdominal radiograph only. In one infant with intestinal malrotation, clinical examination and plain radiography were unremarkable. After definitive surgery, all 24 infants were well at a median age of 14 (7 to 28) months. No surgical cause for bilious vomiting was found in 39 (62%) neonates whose symptoms resolved with conservative management. Conclusions: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae. J Pediatr Surg 37:909-911. Copyright 2002, Elsevier Science (USA). All rights reserved.

‘Spontaneous’ neonatal gastric perforation: Is it really spontaneous?

Background/Purpose: Most historical reports have described gastric perforation in the neonatal population as “spontaneous.” More recently, several variables, including prematurity and nasal ventilation, have been implicated as contributing factors. The authors sought to analyze the etiology, course, and outcome of newborns with spontaneous gastric perforation from one institution over a 16-year period. Methods: The authors reviewed retrospectively the charts of all infants who underwent operation or had perforation of the stomach diagnosed in the newborn period. Results: Among more than 84,000 live births, 7 newborns were identified with perforation of the stomach. Four had coexisting gastrointestinal lesions (2 necrotizing enterocolitis, 1 undiagnosed tracheoesphageal fistula, 1 meconium plug), and 1 received nasal continuous positive airway pressure (CPAP). In only 2 cases were no other gastrointestinal lesions or other presumed contributing factors (nasal CPAP) present, and thus, only 2 cases could be classified as “spontaneous.” Mortality rate was 57%. Three of the patients were premature, all of whom died. Conclusions: Whereas in the older literature, most cases of gastric perforation were considered spontaneous, and were full term, the authors' review of 7 cases over a 16-year period leads us to question the cause as spontaneous. The authors found that prematurity and concomitant gastrointestinal lesions were associated with gastric perforation in the neonate and that few cases truly are spontaneous. The authors suggest that when gastric perforation occurs in neonates, a contributing cause should be sought. J Pediatr Surg 35:1066-1069. Copyright © 2000 by W.B. Saunders Company.

Intestinal emergencies in newborn infants

Imaging plays a major role in most neonatal gastrointestinal emergencies. The role may vary from helping to establish a diagnosis, to the evaluation of associated abnormalities, to surgical planning, or to therapy for some conditions like meconium ileus or meconium plug syndrome. Plain radiographs and ultrasound serve a primary imaging modalities with bowel contrast examinations, CT scan, and MR imaging playing roles in more complex cases.

Gastrointestinal manifestations of cystic fibrosis: radiologic-pathologic correlation.

Cystic fibrosis (CF), the most common lethal autosomal recessive disease in white populations, is characterized by dysfunctional chloride ion transport across epithelial surfaces. Although recurrent pulmonary infections and pulmonary insufficiency are the principal causes of morbidity and death, gastrointestinal symptoms commonly precede the pulmonary findings and may suggest the diagnosis in infants and young children. The protean gastrointestinal manifestations of CF result primarily from abnormally viscous luminal secretions within hollow viscera and the ducts of solid organs. Bowel obstruction may be present at birth due to meconium ileus or meconium plug syndrome. Complications of meconium ileus include volvulus, small bowel atresia, perforation, and meconium peritonitis with abdominal calcifications. Older children with CF may present with bowel obstruction due to distal intestinal obstruction syndrome or colonic stricture, and tenacious intestinal residue may serve as a lead point for intussusception or cause recurrent rectal prolapse. Radiologic studies often demonstrate thickened intestinal mucosal folds in older children and uncommonly show colonic pneumatosis, peptic esophageal stricture due to gastroesophageal reflux, and duodenal ulcer. Appendicitis due to inspissated secretions is uncommon. Obstruction of ducts and ductules produces exocrine pancreatic insufficiency, pancreatitis, cholestasis, cholelithiasis, and cirrhosis with portal hypertension. On imaging studies, the pancreas is commonly small and largely replaced by fat, sometimes displays calcifications, and is rarely replaced by macrocysts. Radiologic features of hepatobiliary disease include an enlarged radiolucent liver from steatosis, gallstones, a shrunken nodular liver, splenomegaly, and portosystemic collateral vessels. With the improved survival of CF patients, an increased risk for developing gastrointestinal carcinomas has been established, many occurring as early as the 3rd decade.

EMERGENCY GASTROINTESTINAL RADIOLOGY OF THE NEWBORN

Imaging plays a major role in most neonatal gastrointestinal emergencies. The role may vary from helping to establish a diagnosis, to the evaluation of associated abnormalities, to surgical planning, or to therapy for some conditions like meconium ileus or meconium plug syndrome. Plain radiographs and bowel contrast examinations serve as primary imaging modalities with ultrasound, CT scan, and MR imaging playing roles in more complex cases.

Is it necrotizing enterocolitis, microcolon of prematurity, or delayed meconium plug? A dilemma in the tiny premature infant

Failure of a small premature newborn to adequately evacuate meconium for days or weeks has been attributed to “probable necrotizing enterocolitis (NEC)” or “microcolon of prematurity.” The authors present an unusual type of “meconium plug syndrome” with the same clinical picture, seen in tiny premature babies (500 to 1,500 g), which required a contrast enema or Gastrografin upper gastrointestinal (UGI) series to evacuate the plugs. The obstruction resolved. Twenty babies (480 to 1,500 g) presented with the same clinical picture without any x-ray suggestion of NEC; contrast enemas were performed because of the suspicion of meconium plug syndrome. All 20 had extensive meconium plugs that were evacuated by the enema or by a Gastrografin UGI series. Most of them improved after the plugs were passed. These infants differ from typical full-term babies with meconium plug syndrome in a number of ways: (1) many of the mothers were on magnesium sulfate (MgSO 4) or had eclampsia; (2) the plugs were diagnosed late rather than shortly after birth; and (3) the plugs were significant, extending to the right colon. The authors believe that when a tiny premature baby has findings consistent with meconium plug syndrome, the baby should be transported to radiology, for a Gastrografin enema, despite the difficulties involved. Delay postpones the start of feedings, and increses the number of radiographic studies.