This male infant was the product of a cesarean section after 38 weeks of gestation. At birth his
Apgar score was 9 and he weighed 7 lb. The
ini-tial physical examination revealed no abnormalities
(Received December 30, 1968; revision accepted for publication May 15, 1969.)
ADDRESS: (E.I.G.) Department of Radiology, West Valley Community Hospital, 5333 Balboa
Boulevard, Encino, California 91316.
PEDIATRICS, Vol. 44, No. 4, October 1969
RECTAL
THERMOMETER-INDUCED
PNEUMOPERITONEUM
IN
THE
NEWBORN
Report
of
Two
Cases
Edward I. Greenbaum, M.D., Merle Carson, M.D., William N. Kincannon, M.D.,
and Bernard J. O’Loughlin, Ph.D., M.D.
Departments of Radiology and Pediatrics, University of California,
Irvine-Orange County Medical Center, California
ABSTRACT. Two cases of pneumoperitoneum of
the newborn caused by perforation of the rectum
by a rectal thermometer are presented. The infants
presented with symptoms of respiratory distress
and cyanosis associated with vomiting and
abdomi-nal distention. The literature on the subject is
re-viewed. Only seven such cases have been reported
to date, and the mortality approximates 70%. The single most important factor affecting prognosis
ap-pears to be the state of maturity at the time of re-parative surgery. Of five mature infants operated on within 24 hours of symptoms, four have sur-vived and have done well. We strongly advocate caution in the use of rectal thermometers, and we would suggest that axillary temperatures or flexible rectal probes be used whenever possible.
Pediat-rics, 44:539, 1969, NEwBORN INFANT,
THERMOME-TER, RECTAL, PNEUMOPERITONEUM.
P
NEUMOPERITONETJM in the newborn is arare condition, but it carries with it the grave implication of peritonitis with its
as-sociated high mortality. Any break in the
continuity of the gastrointestinal tract may
give rise to this condition. The nlost com-monly reported causes for this phenomenon
are perforation of the stomach,l duode-num,2 meconium ileus,3 perforation of
Meckel’s diverticulum, and perforation
sec-ondary to an obstructing lesion, such as
ileal atresia and volvulus. Colon perfora-tions have been described in Hirschsprung’s
disease#{176} and in imperforate anus.2
Pneumo-peritoneum in the newborn may be
secon-dary to a pneumomediastinum in which air
dissects caudad in the perivesicular spaces and produces a retroperitoneal emphysema from whence the air may escape into the greater peritoneal sac. In many instances
spontaneous perforation7 of the intestinal
tract resulting in pneumoperitoneum has occurred where no specific underlying etiol-ogy could be found either by the operating surgeon or at autopsy. Many authors offer
explanations for this phenomenon, but the
diversity and number of explanations
im-peach their credibility.
It is the purpose of this paper to review
two instances of pneunloperitoneum of the newborn caused by penetration of a rectal thermometer through the anterior rectal
wall. Only seven similar cases have been re-ported in the world literature to date.
CASE I
This male infant was the product of a normal vaginal delivery after 37 weeks of gestation. He weighed 5 Ib, 143i oz at birth, was considered nor-mal, and was admitted to the newborn nursery,
where a routine rectal temperature was taken. He
did well until approximately 18 hours following birth, when there was onset of dyspnea and cy-anosis. The abdomen was slightly distended and tympanitic, and a pneumatocele of the scrotum was present. Abdominal films (Fig. 1 and 2) re-vealed a gross pneumoperitoneum and the infant was taken to surgery, where a small rent was found in the anterior wall of the rectum just above
the peritoneal reflection. The rectal perforation was closed and a sigmoid colostomy was performed. Following surgery, the patient did well and was discharged on the fifteenth postoperative day.
-“I
540 PERFORATION BY RECTAL THERMOMETER
FIG. 1. Upright view of the abdomen reveals a
large amount of free air under the right
hemidia-phragm outlining the dome of the liver.
and he was sent to the newborn nursery, where a
routine rectal temperature was taken. He remained
well until approximately 16 hours of age when
bile-stained vomitus, abdominal distention, cyanosis,
and respiratory distress very quickly developed.
Abdominal roentgenograms (Fig. 3 and 4)
re-vealed a gross pneumoperitoneum. At surgery
there was a perforation, approximately the size of
a thermometer, of the anterior rectal wall just
proximal to the peritoneal reflection. The
perfora-tion was closed and a sigmoid colostomy was
per-formed. No other abnormalities were noted at lapa-.
rotomy. The child did well following surgery, and
he was discharged approximately 1 month later in
excellent condition.
DISCUSSION
In both of these instances the infants
were normal at birth, and, during the first
24 hours of life, they developed vomiting, abdominal distention, respiratory distress,
and cyanosis-symptoms so characteristic of
intestinal perforation with
pneumoperito-neum. Abdominal films showed gross free air. Temperatures were taken rectally on both infants upon admission to the new-born nursery. This is done not only to re-cord the temperature but also to ensure
pa-tency of the anus. Although good nursing
policy advocates that no more than the
mercury tip be placed in the rectum, it is
easily understandable that with a thrashing,
struggling infant it would be possible for
this rigid instrument to advance and dam-age the rectal wall. Needless to say, a less
judiciously placed thennometer might
im-part the same effect.
The rectum in the infant is directed
ante-riorly immediately proximal to the anus,
with the distance between the anus and
peritoneal reflection over the rectosigmoid
FIG. 2. In the supine view air is seen outlining the
falciform ligament. Both inner and outer walls of multiple loops of small bowel are seen outlined by
Fic. 3. Cross amount of free air is seen under both
hemidiaphragms in this upright view.
ARTICLES 541
being less than 3 cm in the newborn. Thus,
the mechanism of injury becomes obvious. If the rectal thermometer is advanced past 3 cm and is not directed posteriorly, it penetrates the anterior wall of the rectum above the peritoneal reflection. The
perfo-rations were at precisely this location in these two infants. Neither infant had any associated anomaly of the intestine nor was there any history of a prior digital examina-tion, barium enema, or introduction of any
foreign body other than the thermometer. Traumatic perforations of the rectum in
the newborn have been described following routine enemas,8 ‘ diagnostic barium
ene-mas,1#{176}and introduction of catheters to en-sure anal patency.8 These sources of poten-tial injury have been more fully described in the literature and will not be discussed further here. In reviewing the literature,
seven cases of thermometer-induced rectal perforations were found.’4 Five of the seven infants died, making the mortality approximately 70%. It should be stated, however, that three of the five infants who
died were premature, and in one instance the rectal perforation was overlooked at
surgery and found only in retrospect at
au-topsy. In one other instance the infant
sur-vived surgery but died due to massive aspi-rations 3 days later. Both infants in our
series survived, which we attribute not only to early diagnosis and surgery, but also to
the fact that they were mature and there-fore better able to tolerate anesthesia.
The importance of immediate diagnosis and emergency surgery cannot be overem-phasized. The presenting symptoms are suf-ficiently characteristic to demand immedi-ate roentgenograms of the abdomen. The finding of pneumoperitoneum demands immediate surgery. Blood matching and intravenous cutdown are quickly accom-plished, followed by endotracheal anes-thetic. Pre-operative location of the perfora-tion is impossible and wide exposure is necessary through a paramedian incision. Careful inspection of the stomach and duo-denum is first performed and, if no
perfora-tion is found, the entire remaining intestinal
FIG. 4. In the supine view the so-called “football” or “air dome” sign is noted. The oval shadow of
the visceral contents of the abdomen is the football with the falciform liganwnt of the liver forming the seam. Air is seen outlining both inner and outer
542 PERFORATION BY RECTAL THERMOMETER
tract must be carefully investigated.
Instil-lation of Methylene Blue via nasogastric tube or rectal routes often localizes the de-feet. In these two patients, closure of the defect was followed by a temporary cobs-tomy. Parenteral fluids and antibiotics were also used during the postoperative period.
Probably the most important lesson to be learned is prevention of this problem. This should re-emphasize the danger of rectal
thermometers under these circumstances. Axillary temperatures for newborns or the use of flexible rectal probes for this purpose
are strongly recommended for routine use.
SUMMARY
Two instances of pneumoperitoneum of the newborn caused by perforation of the rectum by a rectal thermometer are pre-sented. The infants presented with symp-toms of respiratory distress and cyanosis associated with vomiting and abdominal dis-tention. The literature on the subject is re-viewed. Only seven such cases have been reported to date, and the mortality is
ap-proximately 70%. The single most impor-tant factor affecting prognosis appears to be the state of maturity at the time of repara-tive surgery. Of five mature infants oper-ated on within 24 hours of symptoms, four have survived and have done well. We
strongly advocate caution in the use of
rec-tal thermometers, and we would suggest that axillary temperatures or flexible rectal probes be used whenever possible.
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Acknowledgment
