What Is the Procedure When a Baby Is Born With Meconium
Failure to Laissez passer Meconium: Diagnosing Neonatal Abdominal Obstruction
Am Fam Physician. 1999 Nov 1;60(vii):2043-2050.
Commodity Sections
- Abstract
- Clinical Presentation of Meconium Retentivity
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Timely passage of the commencement stool is a authentication of the well-being of the newborn baby. Failure of a full-term newborn to laissez passer meconium in the first 24 hours may indicate intestinal obstacle. Lower abdominal obstruction may exist associated with disorders such as Hirschsprung's disease, anorectal malformations, meconium plug syndrome, small left colon syndrome, hypoganglionosis, neuronal intestinal dysplasia and megacystis-microcolon-intestinal hypoperistalsis syndrome. Radiologic studies are unremarkably required to brand the diagnosis. In addition, specific tests such equally pelvic magnetic resonance imaging, anorectal manometry and rectal biopsy are helpful in the evaluation of newborns with failure to pass meconium.
The first stool is passed inside 24 hours of birth in 99 percent of good for you full-term infants and inside 48 hours in all good for you total-term infants.1 Failure of a full-term newborn to pass meconium inside the starting time 24 hours should raise a suspicion of intestinal obstruction. Amongst premature infants, however, one study2 revealed that simply 37 percent of 844 preterm infants passed their first stool in the first 24 hours; 32 percent had delayed passage of the first stool beyond 48 hours. In 99 percent of the preterm infants, the first stool was passed by the ninth day later nascence.
Clinical Presentation of Meconium Retentiveness
- Abstract
- Clinical Presentation of Meconium Retentivity
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Failure to pass meconium combined with progressive abdominal distention, refusal to feed and vomiting of bilious abdominal contents are the classic clinical signs of intestinal obstruction in neonates. Abdominal examination often reveals distended loops of bowel, which may be visible or palpable. Anal inspection is essential to exclude the presence of anal atresia, perineal fistula with anal atresia, the membranous grade of anal atresia and anal stenosis.
Plain radiographs of the abdomen do not allow differentiation of small-scale bowel obstruction from large bowel obstruction. The differential diagnosis for small-scale bowel obstacle in neonates includes duodenal atresia, malrotation and volvulus, jejunoileal atresia, meconium ileus and meconium peritonitis. Bilious vomiting, with or without abdominal distention, is unremarkably the first sign of small bowel obstruction. The differential diagnosis for big bowel obstruction in neonates includes Hirschsprung'due south affliction, anorectal malformations and meconium plug syndrome (Table 1).
TABLE 1
Differential Diagnosis of Conditions That May Be Associated with Failure to Pass Meconium in the Newborn
| Diagnosis | Frequency | Abnormal findings | Therapy |
|---|---|---|---|
| Hirschsprung's disease | 1/4,0003 | Tight anus, empty rectum, transition zone | Surgery |
| Meconium plug syndrome | 1/500 to i/1,00010 | Meconium plugs | Rectal stimulation, enema |
| Meconium ileus | 1/2,80012 | Abdominal distention at birth, cystic fibrosis | Enema with intravenous fluids, surgery |
| Anorectal malformation | i/iv,000 to ane/8,00014 | Absent anus, tight anus or fistula | Dilatation, surgery |
| Small left colon syndrome | Rare | Transition zone* at splenic flexure | Enema, rarely, colostomy |
| Hypoganglionosis | Rare | Transition zone* | Medical, TPN, surgery |
| Neuronal intestinal dysplasia type A | Rare | Transition zone,* mucosal Inflammation | Medical, surgery |
| Neuronal intestinal dysplasia type B | Rare | Megacolon | Medical, rarely, surgery |
| Megacystis-microcolon-intestinal hypoperistalsis syndrome | Very rare | Microcolon, megacystis | TPN |
In many cases of suspected neonatal abdominal obstruction, the clinical history and physical examination combined with apparently abdominal radiographs, contrast enema radiographic test, anorectal manometry and rectal biopsy eventually yield the diagnosis. The most difficult management decision is to decide betwixt bourgeois management and emergency surgery. Ideally, all newborns suspected of having bowel obstruction should receive handling at a eye where a pediatric surgeon is available.
ILLUSTRATIVE Example
A 3,480 g (vii lb, vii oz) male person babe was built-in after 40 weeks' gestation. In that location were no complications during the pregnancy and delivery. He did non pass meconium after birth, and he had the onset of vomiting on the start day. His abdomen became mildly distended. The babe was not able to feed, and abdominal distention increased.
Rectal examination revealed a tight anus. On the second day, flat and upright abdominal films demonstrated numerous loops of dilated bowel (Effigy 1a). Barium enema radiographic examination showed that most of the dilated bowel was colon; no transition zone was seen (Figure 1b).
FIGURE 1A.
Plain abdominal radiograph demonstrating numerous loops of dilated bowel. Minor bowel obstruction cannot be differentiated from large bowel obstruction. No gas is visible in the rectum.
Effigy 1B.
Barium enema radiograph showing an incompletely filled, dilated colon. This examination confirms that most of the dilated bowel on the plain pic (Figure 1a) is the colon. No transition zone is visible.
The surgeon performed an anal dilatation, and the infant later passed gas and meconium, which was followed by resolution of all symptoms.
After belch from the infirmary, the baby's mother connected performing periodic anal dilatation because he had difficulties moving his bowel. Digital rectal exam past the physician when the infant was v weeks of historic period revealed a tight anus and liquid stool just no impaction.
I week later on, the mother noticed a bloody ring around his bowel movements. Barium enema radiographic examination at this time showed a transition zone in the distal portion of the sigmoid colon, with marked dilatation of the descending colon and left side of the transverse colon (Effigy 1c). Anorectal manometry showed an absent rectosphincteric reflex. No ganglion cells were seen in the rectal biopsy. These findings were consistent with Hirschsprung'due south disease.
FIGURE 1C.
Barium enema radiograph performed when the babe in Figures 1a and 1b was six weeks of age, revealing a transition zone in the distal portion of the sigmoid colon, with marked dilatation of the descending colon and the left side of the transverse colon. These findings are consistent with Hirschsprung's disease.
Hirschsprung's Disease
- Abstract
- Clinical Presentation of Meconium Retention
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Minor Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Hirschsprung'south disease, or built aganglionic megacolon, has an overall incidence of one in 4,000 live births.iii It accounts for 20 to 25 percentage of the cases of neonatal bowel obstruction.4 The affliction affects four times as many boys equally girls, and 8 pct of patients with Hirschsprung'southward disease besides take Downwardly syndrome.5 The abnormal bowel innervation affects the internal anal sphincter. Most ofttimes, the rectosigmoid is involved, simply a variable length of gut can be involved. A 30-year retrospective study6 revealed that the mean age at diagnosis has decreased to two.6 months because of vigilance on the part of physicians, the utilise of anorectal manometry for assessment of the anal sphincter and early rectal biopsy to confirm the clinical diagnosis.
A common presentation of Hirschsprung's affliction in the newborn is failure to pass meconium during the first few days of life, with subsequent passage of a meconium plug followed by sparse bowel movements. Gastrointestinal bleeding and diarrhea are danger signs for Hirschsprung'due south affliction–associated enterocolitis. Enterocolitis can be fatal and is thought to be due to proliferation of leaner as a result of stasis.
Physical examination frequently reveals the anus and rectum to be narrow and empty of stool. Plain abdominal radiographs prove gas and stool in the colon and oft the distention with stool or gas does not reach distally to the pelvic rim (Figure 1a).
Barium enema radiographic test, performed with the colon unprepared, may reveal a transition zone that separates the pocket-size-to normal-diameter aganglionic bowel from the dilated bowel in a higher place (Figure 1c). A transition zone may not exist recognizable in up to 25 pct of neonates with classic Hirschsprung's disease (Figure 1b). Similarly, a transition zone may non be discernible in patients with ultrashort segment Hirschsprung'due south disease, in patients with total colonic aganglionosis in whom the transition zone is in a higher place the colon and in patients who had an emergency colostomy. The presence of barium in the 24-hr delayed film is also suggestive of Hirschsprung'south affliction.
ANORECTAL MANOMETRY
When possible, anorectal manometry should be performed in all newborns with symptoms of lower bowel obstruction. With anorectal manometry, changes in anal pressure are recorded during and after rectal distention. When ganglion cells are present, rectal distention with a balloon inhibits the internal anal sphincter, resulting in a fall in anal pressure level, called the rectosphincteric reflex (Figure 2a). In patients with Hirschsprung's disease, the rectosphincteric reflex is absent-minded (Figure 2b).
FIGURE 2A.
Anorectal manometric recording of a newborn with delayed passage of stool, showing a normal rectosphincteric reflex every bit demonstrated past the drop in anal pressure in response to rectal distention. The volume indicated is the volume used for rapid rectal distention. Rectal distention inhibits the internal anal sphincter, resulting in a fall in anal culvert force per unit area.
FIGURE 2B.
Anorectal manometric recording of a newborn with Hirschsprung's affliction. The rectosphincteric reflex is absent-minded, manifested past no alter in the anal culvert pressure in response to balloon dilation.
Anorectal manometry is near helpful in excluding the diagnosis of Hirschsprung's illness in a newborn.7,8 If the rectosphincteric reflex is absent, the diagnosis of Hirschsprung's disease needs to be confirmed past rectal suction biopsy, which shows no ganglion cells and markedly increased acetylcholinesterase staining of increased coarse neural fibers inside the muscularis mucosae and the lamina propria.
Handling
Surgery to remove or bypass the diseased bowel is required in all children with Hirschsprung's illness. In most neonates, a colostomy is initially placed into the normal bowel for decompression, followed by corrective surgery in three to six months. Occasionally, a primary pull-through procedure is performed.
Meconium Plug Syndrome
- Abstract
- Clinical Presentation of Meconium Retention
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Meconium plug syndrome is the mildest and most common form of functional distal obstruction in the newborn. 9 It is a transient form of distal colonic or rectal obstacle acquired by inspissated, immobile meconium. The incidence of meconium plug syndrome is estimated to range from one case in 500 to 1 case in 1,000 neonates.ten The etiology of this disorder is unclear.
The plain abdominal radiograph oft reveals generalized gaseous distention of abdominal loops of small and large bowel filling the entire abdomen, but with no fluid levels. Dissimilarity enema is diagnostic, showing the outline of the meconium plug (Figure 3), and also therapeutic if the plug is passed after. In some newborns, rectal stimulation with a thermometer, digital rectal exam or a saline enema induces passage of the plug. Afterward the plug is passed, bowel movements are normal, and all symptoms resolve. Notwithstanding, even neonates with organic illness, such every bit Hirschsprung'due south disease, may pass a meconium plug and do well for a catamenia of time. Therefore, connected ascertainment is required in infants who laissez passer a meconium plug and, if symptoms persist, further work-upwardly is required.
Figure three.
Barium radiograph of a newborn with meconium plug syndrome. Barium outlines multiple plugs of meconium. This infant passed the multiple plugs afterwards the barium enema and so connected to laissez passer normal meconium.
Meconium Ileus
- Abstract
- Clinical Presentation of Meconium Retention
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Another cause of neonatal bowel obstruction by thick tenacious meconium is meconium ileus. Meconium ileus accounts for near 30 percent of cases of intestinal obstruction in newborns.11 In approximately fifty pct of the newborns with meconium ileus, the gut is undamaged and continuity is non disrupted; the obstruction is merely due to intraluminal meconium.nine In the other infants, meconium ileus is associated with volvulus, atresia or perforation.9 Cystic fibrosis is the underlying disorder in most infants with meconium ileus.ix Meconium ileus occurs in 15 percent of patients with cystic fibrosis. 12
Typically, abdominal distention is present at nascency. Within hours, every bit air is swallowed, the distention increases, and the infant vomits bile-stained material. Thickened bowel loops are oftentimes palpable and visible through the intestinal wall. Massive distention, intestinal tenderness or intestinal erythema indicates the presence of complications. Rectal examination is ofttimes difficult because of the pocket-sized caliber of the rectum.
Abdominal radiographs may reveal a distended bowel, few air-fluid levels and, in the right lower abdomen, meconium mixed with air, which has a ground-glass appearance on plainly moving picture. The presence of calcifications, free air or very large air-fluid levels suggests complications. The difference betwixt meconium ileus and meconium plug syndrome is in the site and severity of the obstruction.
Contrast enema radiographic exam demonstrates a microcolon, often with no bowel contents. Reflux of contrast into the pocket-size bowel reveals the plugs. The small bowel is of narrow caliber beneath the plug and dilated above the plug.
Uncomplicated meconium ileus may be successfully treated by assistants of a diatrizoate meglumine (Gastrografin) enema and enough of intravenous fluids; the success rate is xvi percent12 to 50 percent.13 If the Gastrografin enema is unsuccessful, operative evacuation of the obstructing meconium by irrigation will be necessary. Complications such as atresia, perforation and meconium peritonitis ever require firsthand surgery, including resection, intestinal anastomosis and ileostomy.
Anorectal Malformations
- Abstruse
- Clinical Presentation of Meconium Retention
- Hirschsprung'southward Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small-scale Left Colon Syndrome
- Other Causes of Failure to Laissez passer Meconium
- References
One in 4,000 to one in 8,000 newborns is born with an anorectal malformation.14 A spectrum of anomalies of the lower intestinal tract and the genitourinary structures occurs from a failure of the completion of the complex embryologic developmental sequences in which the growth of the urorectal septum, lateral mesoderm structures and ectodermal structures course the normal rectum and lower urinary tract.
ANAL STENOSIS
Anal stenosis accounts for approximately 20 percent of anorectal malformations.4 The anus is very small, and a central black dot of meconium is present. Intense efforts are required to laissez passer a ribbon-similar stool. The diagnosis of anal stenosis is established by demonstration of a small-scale, tight anus. Occasionally, an anal web may be the cause of the small anus. Anal dilatation is the usual treatment for anal stenosis and may demand to exist connected for several months.
ANAL ATRESIA
Anal atresia affects males and females with equal frequency. Perineal inspection reveals the absent anus (Figure 4). Broadly classified, anal atresia is characterized every bit "high" or "depression," depending on whether the rectum ends higher up the levator muscle or partially descends through this musculus. Often, the rectum ends in a fistula. In the high type of anal atresia, the fistula often ends in the prostatic urethra in males and in the vagina in females (Figure 5).
[Effigy unavailable]
Effigy iv.
Imperforate anus in a male babe.
FIGURE 5.
Barium enema radiograph showing evidence of imperforate anus and a vaginal fistula. Barium is present in the vagina (arrow). "PC" marks the pubococcygeal line.
Patients with a low type of anal atresia usually take a well-formed sacrum, a prominent midline groove and a prominent anal dimple. The low lesions are associated with a cutaneous fistula to the perineum. The orifice is pocket-sized, located in the perineum anterior to the center of the external anal sphincter, close to the scrotum in the male person and the vulva in the female. The aberrant anterior position of the fistula opening is occasionally not obvious and is mistaken for the anus. Males often take a black, ribbon-type structure in the perineum, which represents a subepithelial fistula filled with meconium.
Associated anomalies are present in up to 70 percent of patients with anorectal malformation.9 Most l per centum have urologic problems.15 The mnemonic VACTERL is used to describe the clan of a combination of v ertebral defects, a nal atresia, c ardiac defects, t racheoesophageal fistula with e sophageal atresia, r enal defects and radial upper l imb hypoplasia.
Anal atresia requires surgical correction. The goal is to preserve bowel, urinary and sexual function. A colostomy is initially performed in neonates with high anal atresia. If a fistula is present on the perineum or in the vagina, it can be gently dilated to allow the gas and meconium to pass. Low lesions, including those with perineal fistulas, can be corrected electively when the baby's condition is stable.
Modest Left Colon Syndrome
- Abstract
- Clinical Presentation of Meconium Retentiveness
- Hirschsprung's Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
A rare crusade of neonatal intestinal obstruction is small left colon syndrome, a functional distal bowel obstruction secondary to transient dysmotility in the descending colon.xvi With this disorder, abdominal distention often develops after the newborn has passed meconium. More than than fifty per centum of newborns with small left colon syndrome are infants of mothers who have diabetes or an aberrant glucose tolerance examination.xvi Other infants are hypoglycemic or septic and, in others, an association with hypothyroidism, hypermagnesemia and maternal apply of psychotropic drugs has been reported.
Plain radiograph shows dilated intestinal loops (Figure 6a) and, often, air-fluid levels. Contrast studies show the colon to be shortened and to lack the usual tortuosity from the anus to the splenic flexure. A sharp transition zone is seen at the splenic flexure (Effigy 6b).
Effigy 6A.
Evidently radiograph of an infant with small left colon syndrome. Dilated intestinal loops are visualized.
Figure 6B.
[ corrected] Barium enema radiograph of the babe in Figure 6a, showing a sharp transition zone at the splenic flexure.
Rectal biopsy in patients with small left colon syndrome shows ganglion cells, reverse to the absence of ganglion cells in patients with Hirschsprung's disease. The ganglion cells tin can be normal, young or hyperganglionic. The clinical course in newborns with pocket-sized left colon syndrome varies in severity from mild symptoms, which may be relieved by the contrast enema, to severe bowel obstacle requiring a temporary transverse colostomy.sixteen Newborns with small left colon syndrome eventually accept normal intestinal move.
Other Causes of Failure to Pass Meconium
- Abstract
- Clinical Presentation of Meconium Retention
- Hirschsprung'south Disease
- Meconium Plug Syndrome
- Meconium Ileus
- Anorectal Malformations
- Small-scale Left Colon Syndrome
- Other Causes of Failure to Pass Meconium
- References
Various maternal medical weather tin cause a delay in meconium passage. In addition, maternal drug utilise, such as illicit drugs, magnesium sulfate and ganglionic blocking agents, can touch on the infant and interfere with the passage of meconium. Neonatal medical conditions that tin can be associated with a failure to pass meconium include hypothyroidism, hypercalcemia, hypokalemia, sepsis and congestive heart failure.
Hypoganglionosis and neuronal abdominal dysplasia type A can produce symptoms and radiographic findings like to those of Hirschsprung'south disease.17–21 Both of these diseases are rare. They can affect part of or all of the gastrointestinal tract and sometimes occur in combination with Hirschsprung'south disease. Histologically, hypoganglionosis is characterized by a reduced number of ganglion cells. In neuronal abdominal dysplasia type A, histologic features include hypoplasia or aplasia of the sympathetic innervation of the myenteric plexus and mucosa, along with mucosal inflammation.
Neuronal intestinal dysplasia blazon B may be manifested in the newborn period as meconium plug syndrome, small left colon syndrome or megacystis-microcolon-intestinal hypoperistalsis syndrome. The biopsy shows a dysplastic submucosal plexus and numerous giant ganglia, with many giant and minor ganglion cells.
Various medications, fractional or total parenteral nutrition, or surgery to remove or bypass segments of bowel may exist necessary in patients with hypoganglionosis and neuronal intestinal dysplasia.
Some other rare crusade of neonatal intestinal obstruction is the megacystis-microcolon-intestinal hypoperistalsis syndrome.22 In this disorder, the pocket-sized bowel is dilated and shortened, and the colon is a microcolon (Figure 7). In that location is an abundance of ganglion cells in the entire gastrointestinal tract. All patients with this syndrome accept megacystis and megaureters, and virtually eventually die of complications from the disorder.
Effigy vii.
Barium enema radiograph in an infant with megacystis-microcolon-intestinal hypoperistalsis syndrome. The duodenum and proximal jejunum are mildly dilated. At that place was no significant progression of the contrast medium into the distal modest bowel. The ligament of Treitz is to the right of the midline (malrotation). A colon series was performed three days before the barium enema, but dissimilarity is still visible in the tortuous and abnormally positioned small colon. In addition, the urinary float is big and thickened, and reflux is present in the right dilated arrangement.
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16. Heaton ND, Howard ER, Garrett JR. Modest left colon syndrome: an immature enteric plexus. J R Soc Med. 1991;84(2):113–4.
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Coordinators of this series are Thomas J. Barloon, Yard.D., associate professor of radiology, and George R. Bergus, M.D., associate professor of family practice, both at the University of Iowa College of Medicine, Iowa City.
The editors of AFP welcome the submission of manuscripts for the Radiologic Controlling series. Send submissions to Jay Siwek, Chiliad.D., following the guidelines provided in "Information for Authors."
Copyright © 1999 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing information technology online may make one printout of the cloth and may use that printout only for his or her personal, non-commercial reference. This cloth may non otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except every bit authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.
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