• Relatively infrequent complication in neonates and early infancy 
  
  • most common cause in neonates is iatrogenic
• Neonates (especially preterm) requiring endotracheal intubation, nasogastric tube (NGT) insertion and oropharyngeal suction are at increased risk of trauma to:
  • pharynx
  • upper airway
  • oesophagus
• Site of injury is often at pharyngoesophageal junction where lumen is narrowed by cricopharyngeal muscle
• Contrast oesophagram and direct visualisation (ultrathin flexible endoscopy) are gold standards for diagnosis

Iatrogenic oesophageal perforation

Complications

• Pneumothorax
• Pneumomediastinum with associated infection
• Pseudo-diverticulum formation
• Surgical/subcutaneous emphysema
• Delayed initiation of feeding
• Upper GI bleeding
• Oesophageal obstruction 

• Preterm babies (especially <1500 g)
• Babies requiring multiple intubation attempts
• Difficulty in passing or forceful attempts at NGT insertion

Clinical

• Difficulty in passing NGT
• NGT bouncing back
• Blood stained aspirates
• Bloody secretions in oropharynx
• Deterioration in clinical condition 

Radiological

• Discuss with radiologist urgently if NGT appears:
  
  • displaced
  • to the right of the midline/vertebral spine
  • not in the stomach
  • not following normal anatomical curvature towards the stomach
  • follows a straight line in the midline towards abdomen 

Suspect oesophageal perforation if:

• Pneumomediastinum
• Pneumothorax
• Cervical crepitus
• Subcutaneous emphysema
• Retropharyngeal gas 

Difficulty passing NGT

• Do not make any further attempts to pass NGT
• Request a water soluble contrast study (discuss with radiologist)

• Early recognition is important (most important prognostic factor is the time between injury and initiation of therapy) 
• Stop feeds
• Prescribe PN
• Remove NGT
  
  • do not re-insert or manipulate NGT
• If requiring ventilatory support, not for non-invasive ventilation
• Discuss with local paediatric surgical team
  
  • send images by PACS
• Maintain close liaison with surgical team regarding: 
  
  • antibiotics
  • duration of nil-by-mouth
  • progress
• Consider transfer to tertiary/surgical centre 
• Keep parents updated regularly
• Document completion of duty of candour in medical records