Microcolon of prematurity: a form of functional obstruction

Bedside ultrasound-guided contrast enema for preterm infants with suspected meconium plug syndrome: a 10-year single-center experience

OBJECTIVES

To evaluate the safety and efficacy of bedside ultrasound-guided contrast enema (US-enema) in the neonatal intensive care unit (NICU) and to assess factors associated with its outcome.

MATERIALS AND METHODS

This retrospective study included preterm NICU babies who underwent US-enema for suspected meconium plug syndrome between 2014 and 2023. Patient characteristics, procedure-related factors, necrotizing enterocolitis (NEC) grades on US, presence of microcolon, and outcomes were reviewed. Group comparison and correlation analyses were performed.

RESULTS

Eighty-two patients (mean gestational age at birth, 27.1 ± 2.5 weeks; mean birth weight, 872.0 ± 378.5 g; 45 males) with 128 sessions of US-enema were enrolled. Forty patients had no NEC, 32 had grade 1 NEC, and 10 had grade 2 NEC. Enema was repeated in 37 patients (45.1%), up to four times. The mean age at initial US-enema was 17.3 days. US-enema was successful in 68.3% (56/82) of patients. There were three events (3/128, 2.3%) of bowel perforation during enema, all had microcolon (p = 0.02), and two cases (2/82, 2.4%) of bowel-related mortality. Patients with enema success had higher gestational age at birth (27.6 vs. 25.9 weeks; p = 0.006), were older at initial enema (19.3 vs. 13.0 days; p = 0.02), and showed microcolon less frequently (12.5% (7/56) vs. 61.5% (16/26); p < 0.001) than those with enema failure.

CONCLUSION

US-enema is safe and effective for preterm NICU babies with suspected meconium plug syndrome. Higher gestational age at birth and older age at enema without microcolon were associated with successful enema.

KEY POINTS

Question Bedside ultrasound-guided contrast enema (US-enema) is considered an effective technique for preterm neonates with meconium plug syndrome, but data on outcome-related factors are limited. Findings US-enema successfully treated 68.3% of patients, with a 2.3% rate of bowel perforation. Higher gestational/postnatal age and absence of microcolon were associated with successful enemas. Clinical relevance US-enema is an effective and safe technique for meconium plug syndrome with a low risk of complications. Preterm neonates with higher gestational age at birth, older age at the time of enema, and without microcolon showed better treatment responses.

Meconium Ileal Obstruction and Functional Immaturity: Review

INTRODUCTION

Ileal obstruction caused by thick meconium associated with functional immaturity (IOMFI) is an uncommon disease associated with prematurity. IOMFI is not well known, and late or wrong diagnosis is a problem. In this research, we review the clinical characteristics and therapeutic methods of IOMFI.

METHODS

Critical descriptive literature review.

RESULTS

Most patients eliminate meconium previously to IOMFI. More premature babies tend to become symptomatic in their second week of life, with progressive abdominal distension. The most frequent complication is perforation. Radiologically there is diffuse intestinal distention without air-fluid levels. In contrast enema a caliber transition zone is observed in the distal ileum with multiple filling defects in the ileum and colon. Neural ganglia are present in biopsies from the rectum, colon, and stoma, mostly with characteristics of immature ganglia. Most patients respond to treatment with water soluble contrast enemas. Surgery is needed for patients who do not respond to enemas and those presenting perforations.

DISCUSSION

IOMFI literature is limited to retrospective mainly small and heterogeneous cohorts. Patients usually respond promptly to water soluble enemas, but a favorable response is highly dependent in contrast reflux through the ileocecal valve and success is related to early treatment. Contrast inflow may be controlled by intermittent radiographies or real time ultrasound.

Clinical and growth outcomes after meconium-related ileus improved with Gastrografin enema in very low birth weight infants

Background

Meconium-related ileus in very low birth weight infants can lead to increased morbidity or mortality and prolonged hospitalization without prompt diagnosis and treatment. This study primarily aimed to identify the incidence of and factors associated with meconium-related ileus and secondarily sought to investigate clinical and growth outcomes after water-soluble contrast media (Gastrografin) enema.

Methods

We retrospectively reviewed medical records of very low birth weight infants born between February 2009 and March 2019 in the neonatal intensive care unit of a single medical center. Perinatal factors, clinical outcomes, and growth outcomes were compared between the group with meconium-related ileus that received Gastrografin enema and the control group.

Results

Twenty-four (6.9%) patients were diagnosed with meconium-related ileus among 347 very low birth weight infants. All achieved successful evacuation of meconium with an average of 2.8 (range: 1–8) Gastrografin enema attempts without procedure-related complications. Initiation of Gastrografin enema was performed at mean 7.0 days (range: 2–16) after birth. Incidences of moderate to severe bronchopulmonary dysplasia were higher and the duration of mechanical ventilation and need for oxygen were longer in the meconium-related ileus group (P = 0.039, 0.046, 0.048, respectively). Meconium-related ileus infants took more time to start enteral feeding and the nothing per oral time was longer (P = 0.001 and 0.018, respectively). However, time to achieve full enteral feeding and Z-scores for weight and height at 37 weeks and at 6 months corrected age did not differ between the two groups.

Conclusions

Gastrografin enema in very low birth weight infants with meconium-related ileus was an effective and safe medical management. Following Gastrografin enema, very low birth weight infants with meconium-related ileus achieved similar subsequent feeding progress and similar growth levels as the control groups without meconium-related ileus.

Diagnostic performance and role of the contrast enema for low intestinal obstruction in neonates

PURPOSE

We aim to evaluate the diagnostic performance and relationship between clinical characteristics, imaging findings, and final diagnosis for the neonatal contrast enema (CE).

METHODS

Retrospective 10-year review of all neonatal CEs including imaging findings, clinical information, indication, and final diagnosis from discharge summaries, surgical reports, and pathology (reference standard). Two blinded pediatric radiologists reinterpreted 366 CEs for obstruction, microcolon, rectosigmoid index (RSI), serrations, meconium, ileal cut-off, transition zone, diagnosis, and level of confidence. CE diagnostic performance was calculated versus reference standard.

RESULTS

Diagnoses included Hirschsprung disease (HD) (15.8%), small left colon syndrome (14.8%), small intestinal atresia/colonic atresia (SIA/CA) (12.6%), meconium ileus (MI) (4.4%), and normal (48.9%). CE had a moderate specificity (87.7%) and low sensitivity (65.5%) for HD; abnormal RSI and serrations showed high specificities (90.3%, 97.4%) but low sensitivities (46.6%, 17.2%). CE showed high specificity (97.4%) and low sensitivity (56.3%) for MI blinded to cystic fibrosis status. Microcolon was specific (96.6%) but not sensitive (68.8%) for MI. CE showed highest PPV (73.1%) (specificity 95.6%, sensitivity 82.6%) for SIA/CA. Microcolon with an abrupt cut-off was specific (99.1%) but not sensitive (41.3%) for atresias.

CONCLUSION

Neonatal CE demonstrates high specificities and low to moderate sensitivities across all diagnoses, with lowest performance in HD.

CLINICAL TRIAL REGISTRATION

None.

Antenatal magnesium sulphate and adverse neonatal outcomes: A systematic review and meta-analysis

BACKGROUND

There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes.

METHODS AND FINDINGS

CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only.

CONCLUSIONS

Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.

Prevention of meconium obstruction in very low birth weight preterm infants

INTRODUCTION

Delayed meconium expulsion is a cause of bowel obstruction in the extremely premature newborn (<28 WGE) weighing less than 1500g at birth.

OBJECTIVE

To evaluate the efficacy of conservative treatment in the prevention of meconium obstruction in very-low-birt- weight preterm infants.

METHOD

Descriptive and retrospective study performed at the Neonatal Intensive Care Unit of a tertiary level hospital. All very-low-birth-weight preterm infants who were born during the study period, from August 2016 to January 2017, and who had meconium obstruction were included.

RESULTS

A sample of 42 newborn infants was obtained. Regarding the expulsion of meconium, 57.1% of the sample spontaneously ejected meconium, while 42.9% received different treatments. Of these, 72.2% were treated with saline enemas, 16% with acetylcysteine enemas, 16% with Gastrografin^® and none required surgical treatment.

CONCLUSION

Conservative treatment seems to be an effective therapeutic measure for the prevention of meconium obstruction in very-low-birth-weight preterm infants since it achieved the expulsion of meconium without having to apply surgical treatment.

Ultrasound-guided contrast enema for meconium obstruction in very low birth weight infants: Factors that affect treatment success

INTRODUCTION

This study aimed to assess the therapeutic results of ultrasound (US)-guided water-soluble contrast enema in very low birth weight (VLBW) preterm infants (<1,500 g) with meconium obstruction and to study factors that affect therapeutic results.

METHODS

This study included a total of 33 consecutive VLBW infants with clinically diagnosed meconium obstruction underwent US-guided water-soluble contrast enema, from April 2007 to March 2014. Patients were classified into two groups based on to procedure outcome: the success group (evacuation of the meconium plug resolution followed by improved bowel distention within 2 days of the procedure, without additional interventions), and the failure group (the contrast enema failed to relieve the obstruction, or other procedure-related complications occurred). Patient- and mother-related clinical factors and procedure-related factors were compared between both groups.

RESULTS

Overall success rate was 54.5%, with 18 successful (M:F=10:8), and 15 failure (M:F=7:8) cases. When compared with the failure group, the success group patients showed statistically significant older gestational age (29(+1) vs. 27 weeks; p=0.028), larger birth weight (1023.1g vs. 790.3g; p=0.048), and higher body weight on the day of the procedure (1036.2g vs. 801.6g, p=0.049). However, no statistically significant differences were seen between other patient and maternal factors. Among the procedure-related factors, retrial of contrast injection during the procedure was associated with significantly higher success than the single trial (p=0.027). The presence of refluxed contrast into the distal ileum was the statistically significant predictor for success of the procedure (p=0.038). There were three cases of bowel perforation (9.1% per person).

CONCLUSION

US-guided water-soluble contrast enema in VLBW infants with meconium obstruction showed a 54.5% success rate and a 9.1% perforation rate per person. Among the procedure-related factors, retrial of contrast injection during the procedure and the presence of refluxed contrast into the distal ileum were related to the success of the procedure.

A pattern-based approach to bowel obstruction in the newborn

Intestinal obstruction is common in newborns, and the radiologist plays a critical role in the care of these children. Diagnosing and managing the potentially obstructed newborn can be challenging, especially given the myriad underlying pathologies that range from benign to acutely life-threatening. A familiarity with the most common diagnoses is essential, but equally important to the radiologist is a systematic approach to management of the child in this setting. We propose an approach based on the recognition of eight radiographic patterns, five upper gastrointestinal examination (UGI) patterns and four contrast enema patterns. Recognition of these patterns directs further imaging when necessary and allows triage of children who can be managed medically, those requiring elective or urgent surgery and those requiring emergent surgery.

Butyrate enemas enhance both cholinergic and nitrergic phenotype of myenteric neurons and neuromuscular transmission in newborn rat colon

Postnatal changes in the enteric nervous system (ENS) are involved in the establishment of colonic motility. In adult rats, butyrate induced neuroplastic changes in the ENS, leading to enhanced colonic motility. Whether butyrate can induce similar changes during the postnatal period remains unknown. Enemas (Na-butyrate) were performed daily in rat pups between postnatal day (PND) 7 and PND 17. Effects of butyrate were evaluated on morphological and histological parameters in the distal colon at PND 21. The neurochemical phenotype of colonic submucosal and myenteric neurons was analyzed using antibodies against Hu, choline acetyltransferase (ChAT), and neuronal nitric oxide synthase (nNOS). Colonic motility and neuromuscular transmission was assessed in vivo and ex vivo. Butyrate (2.5 mM) enemas had no impact on pup growth and histological parameters compared with control. Butyrate did not modify the number of Hu-immunoreactive (IR) neurons per ganglia. A significant increase in the proportion (per Hu-IR neurons) of nNOS-IR myenteric and submucosal neurons and ChAT-IR myenteric neurons was observed in the distal colon after butyrate enemas compared with control. In addition, butyrate induced a significant increase in both nitrergic and cholinergic components of the neuromuscular transmission compared with control. Finally, butyrate increased distal colonic transit time compared with control. We concluded that butyrate enemas induced neuroplastic changes in myenteric and submucosal neurons, leading to changes in gastrointestinal functions. Our results support exploration of butyrate as potential therapy for motility disorders in preterm infants with delayed maturation of the ENS.

Congenital mesenteric defect: Description of a rare cause of distal intestinal obstruction in a neonate

INTRODUCTION

Internal hernias are a rare cause of bowel obstruction in the neonate and present with bilious vomiting. Newborns may be at risk of loss of significant length of bowel if this rare condition is not considered in the differential diagnosis of bilious emesis.

PRESENTATION OF CASE

We report a case of a twin with an internal hernia through a defect in the ileal mesentery who presented with neonatal bowel obstruction. The patient had a microcolon on the contrast enema suggesting that the likely etiology was an intra-uterine event most likely a vascular accident that prevented satisfactory meconium passage into the colon.

DISCUSSION

An internal hernia is rarely considered in the differential diagnosis of distal bowel obstruction in a neonate with a microcolon. Congenital trans-mesenteric hernias constitute only 5-10% of internal hernias. True diagnosis of trans-mesenteric hernias is difficult due to lack of specific radiology or laboratory findings to confirm the suspicion.

CONCLUSION

When clinical and radiological findings are not classical, rare possibilities such as an internal hernia must be considered in the differential diagnosis, to avoid catastrophic bowel loss.

Pathology of gastrointestinal organs in a porcine model of cystic fibrosis

Cystic fibrosis (CF), which is caused by mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR), is characterized by multiorgan pathology that begins early in life. To better understand the initial stages of disease, we studied the gastrointestinal pathology of CFTR-/- pigs. By studying newborns, we avoided secondary changes attributable to environmental interactions, infection, or disease progression. Lesions resembling those in humans with CF were detected in intestine, pancreas, liver, gallbladder, and cystic duct. These organs had four common features. First, disease was accelerated compared with that in humans, which could provide a strategy to discover modifying factors. Second, affected organs showed variable hyperplastic, metaplastic, and connective tissue changes, indicating that remodeling was a dynamic component of fetal life. Third, cellular inflammation was often mild to moderate and not always present, which raises new questions as to the role of cellular inflammation in early disease pathogenesis. Fourth, epithelial mucus-producing cells were often increased, producing a striking accumulation of mucus with a layered appearance and resilient structure. Thus, mucus cell hyperplasia and mucus accumulation play prominent roles in early disease. Our findings also have implications for CF lung disease, and they lay the foundation for a better understanding of CF pathogenesis.

Management of meconium-related ileus in very low-birthweight infants

BACKGROUND

Although administration of a water-soluble contrast enema has been recognized to be effective for meconium-related ileus, there have been no definitive management guidelines for very low-birthweight infants.

METHODS

Between 1998 and 2004, 10 infants without cystic fibrosis were treated for meconium-related ileus at Toyohashi Municipal Hospital. Their treatment and clinical course were reviewed retrospectively.

RESULTS

The average gestational age and birthweight of the 10 infants was 27 weeks and 788 g, respectively. The average age at initiation of treatment with a water-soluble contrast enema was 6.8 days. Intestinal obstruction was relieved by the enema in eight of 10 patients, while one underwent laparotomy and one died without any improvement of obstruction. In both neonates for whom the enema failed, rectal examination and rectal irrigation had been performed for several days before the enema was administered at the age of 14 and 15 days, respectively. In contrast, the enema was administered at the age of 1-11 days in neonates for whom this treatment was successful. Obstruction was relieved if the contrast medium reached the distal ileum, but enemas without reflux into the distal ileum failed to improve the obstruction. Contrast medium passed through the ileocecal valve to reach the distal ileum in all procedures done under fluoroscopy, but the medium failed to reach the ileum in most of the procedures done without fluoroscopy.

CONCLUSION

Although administration of water-soluble contrast enemas can be effective for meconium-related ileus, reflux into the terminal ileum is essential for bowel obstruction to improve, so it is desirable to perform the procedure under fluoroscopic guidance.

Imaging of congenital anomalies of the gastrointestinal tract

The radiological imaging plays a vital role in the evaluation of patients with congenital anomalies of the gastrointestinal tract. The evaluation of these patients, most of which present early after birth, frequently requires the use of various imaging modalities for making the correct diagnosis and planning surgical correction. This article reviews the common congenital anomalies of the gastrointestinal tract including obstructive lesions, anomalies of rotation and fixation, anorectal anomalies, and intestinal duplications. The plain radiograph is often diagnostic in neonates with complete gastric of upper intestinal obstruction and further radiologic evaluation may be unnecessary. An upper gastrointestinal series should be performed in all patients with incomplete intestinal obstruction. Sonography is useful in the evaluation of many congenital anomalies affecting pediatric gastrointestinal tract especially hypertrophic pyloric stenosis, enteric duplication cysts, midgut malrotation, meconium ileus and meconium peritonitis. Moreover, CT and MRI has assumed a greater importance as these provide excellent anatomic details which may be necessary for correct diagnosis as well as treatment planning. This is particularly true in evaluation of congenital anomalies such as esophageal/enteric duplications, vascular rings and anorectal anomalies. It is important to be familiar with the role nad usefulness of the various imaging modalities so that these can be used judiciously to avoid unnecessary radiation exposure while minimizing the patient discomfort.

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 cesarean 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 diseases in infants with very low birth weight

Retained meconium resulting in intestinal obstruction in infants with very low birth weight (VLBW) may cause significant morbidity and even mortality. Immature intestinal neuromuscular function, abnormal meconium composition, and maternal magnesium sulfate therapy results in delay of first meconium passage. This "normal" passage of first meconium may not occur until 1 week of life or later. A spectrum of conditions results from this delayed passage. At the most serious end of this continuum is intestinal obstruction. These patients present with abdominal distension, emesis, and reduced stool frequency. Early diagnosis of this condition using plain abdominal radiographs and contrast enemas where appropriate is imperative. Contrast enemas may be both diagnostic and therapeutic. Most patients do not need surgical intervention. Operation is indicated when enemas fail to relieve the obstruction or perforation occurs. Prompt diagnosis and appropriate management results in a good outcome. Meconium obstruction in VLBW infants does not appear to be associated with cystic fibrosis or Hirschsprung's disease.

Congenital anomalies of the small intestine, colon, and rectum

Congenital anomalies of the gastrointestinal tract are a significant cause of morbidity in children and, less frequently, in adults. These abnormalities include developmental obstructive defects of the small intestine, anomalies of the colon, anomalies of rotation and fixation, anorectal anomalies, and intestinal duplications. Neonates with complete high intestinal obstruction do not usually require further radiologic evaluation following radiography, whereas those with complete low obstruction should undergo a contrast material enema examination. An upper gastrointestinal series must be performed in all patients with incomplete intestinal obstruction because management is different in each case. In low intestinal obstruction, ultrasonography (US) may help differentiate between small bowel obstruction and colonic obstruction. In addition, US can help correctly identify meconium ileus and meconium peritonitis and is useful in the diagnosis of enteric duplication cysts. In malrotation and anorectal anomalies, computed tomography (CT) and magnetic resonance (MR) imaging can provide superb anatomic detail and added diagnostic specificity. Intestinal duplications manifest as an abdominal mass at radiography, contrast enema examination, or US. At CT, most duplications manifest as smoothly rounded, fluid-filled cysts or tubular structures with thin, slightly enhancing walls. At MR imaging, the intracystic fluid has heterogeneous signal intensity on T1-weighted images and homogeneous high signal intensity on T2-weighted images. Familiarity with these gastrointestinal abnormalities is essential for correct diagnosis and appropriate management.

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 (MgSO4) 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 increases the number of radiographic studies.