Patient Presentation
A 2-day-old female was in the newborn nursery. She was a term infant, born to a G2P2 mother without complications. It was noted before rounds that she was almost 48 hours old and had not passed any meconium. She was acting normally and breastfeeding well every 2-3 hours. Her routine labs had been sent at 24 hours of age including her newborn screening test and its results were pending.
The pertinent physical exam showed her birth weight of 3.489 kg which was down only 4%. Her head circumference and length were about 50%. She was mildly jaundiced with a transdermal bilirubin of 4.7 mg/dL. Her examination was normal. She had no sacral anomalies, her lower extremity reflexes were normal, and her anus appeared in a normal position with a tiny amount of meconium on the anal folds.
The diagnosis of a healthy female infant who had not yet passed meconium was made. The attending and resident discussed the potential differential diagnosis. While seeing the other babies during rounds, the nurse messaged the pediatricians that the infant had had a large meconium stool at 51 hours of life. The patient’s clinical course as of 1 month of age, showed that the infant had been passing regular stools without any problems and was growing well.
Discussion
Clinicians who work with newborn infants are similar to systems engineers. They need to make sure that all of the major organ systems are working as they should be at birth and making the appropriate transition to full operations over the first few days. Obviously the cardiorespiratory system needs to be working from the start, but other systems such as the urinary and gastrointestinal systems should start working soon after birth.
According to a 1977 study of 500 consecutive infants of all gestational ages, first void was within 24 hours for all infants. First stool was within 48 hours for 499 infants. Most first stools were within the first 24 hours (N=395, 98.5% for term infants, N= 80, 76.3% for preterm infants and N=25, 100% for post term infants) Delayed passage is usually considered after 48 hours.
Babies with delayed passage of meconium may be well appearing and have a normal physical examination. They can also present with obstructive symptoms include abdominal distention, poor feeding, vomiting, and respiratory problems.
Prematurity issues have increased because of the incredible medical advances in neonatology and obstetrics. More mothers are being treated with various medications, babies are often younger and have more respiratory problems and/or infections which can cause delayed meconium passage. More extremely premature infants simply have not developed their gastrointestinal neural connections to be able to have normal peristalsis and evacuation in the way an older premature infant or full term infant does. On the plus side in the US, more infants are being identified with possible cystic fibrosis prenatally or with newborn screening. Similarly hypothyroidism is usually identified early because of newborn screening.
An anteriorly positioned anus still allows stool passage but it is more difficult as the rectum/anus is longer and also the angle relative to the skin is more acute. Imperforate anus usually can be identified on physical examination. It should be noted that fistulas may still have passage of stool but potentially symptoms will be more constipation like or the stool is smaller/ribbon-like. Other abnormalities may cause bilious emesis which is a medical emergency. A review can be found here.
Hirschsprung disease (HD) is one of the most common dysmotility problems associated with delayed passage of meconium and often is the first cause clinicians consider. HD is caused by agangionic bowel that begins at the rectum/anus and ascends. It can affect the entire colon but often there is a transition point between normally innervated colon and non-innervated colon which can be identified on contrast enema. Anorectal manometry can help with the diagnosis but colonic biopsy is the definitive test.
Evaluation and treatment for delayed passage of meconium is not standardized. Assuming there is normal external anatomy and the infant is well, patency testing is commonly used as a first evaluation/treatment method. This can be insertion of a tube and/or medication such as a glycerin suppository. This not only tests patency within the first couple of centimeters of colon but may also stimulate evacuation. Contrast enema again provides not only evaluation for Hirschsprung disease, meconium ileus, and potential anatomic abnormalities, but often is therapeutic by stimulating evacuation.
Learning Point
Causes of delayed passage of meconium include:
- Mother treated with magnesium, other medications
- Prematurity due to immaturity of the intestinal motility
- Functional ileus due to infection (sepsis, pneumonia), electrolyte abnormalities
- Dysmotility including Hirschsprung disease
- Anatomic abnormalities – malpositioned anus, imperforate anus, intestinal atresia / web, duplications, fistula, cloacal malformation
- Malrotation or volvulus
- Cystic fibrosis – meconium ileus
- Hypothyroidism
Questions for Further Discussion
1. What are potential causes of abdominal distention? A review can be found here
2. What problems can meconium cause? A review can be found here
3. What are potential causes of constipation? A review can be found here
Related Cases
- Disease: Delayed Passage of Meconium | Infant and Newborn Care | Constipation
- Symptom/Presentation: Constipation and Encopresis
- Specialty: Gastroenterology | Neonatology
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Common Infant and Newborn Problems and Intestinal Obstruction.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Clark DA. Times of First Void and First Stool in 500 Newborns. Pediatrics. 1977:60(4);457-59.
Karakus SC, Kilincaslan H, Sarsu SB, et al. The passage of meconium alone is not a sign of correctly positioned anus. The Journal of Maternal-Fetal & Neonatal Medicine. 2015;28(3):303-305. doi:10.3109/14767058.2014.916267
Gfroerer S, Rolle U. Pediatric intestinal motility disorders. World J Gastroenterol. 2015;21(33):9683-9687. doi:10.3748/wjg.v21.i33.9683
Mataya L, Lysouvakon P. Case 4: Delayed Passage of Meconium, Abdominal Distention, and Emesis in a 2-day-old Girl. Pediatrics In Review. 2019;40(6):310-312. doi:10.1542/pir.2017-0069
Lange M, Figura Y, Bohne C, Beske F, Bohnhorst B, Heep A. Management of prolonged meconium evacuation in preterm infants: A survey-based analysis in German Neonatal Intensive Care Units. Acta Paediatrica. 2022;111(11):2082-2089. doi:10.1111/apa.16528
Montalva L, Cheng LS, Kapur R, et al. Hirschsprung disease. Nat Rev Dis Primers. 2023;9(1):1-19. doi:10.1038/s41572-023-00465-y
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa