This Signal is about the risk of missed diagnosis of imperforate anus in newborn babies.
A sample incident reads:
“On examination of baby by paediatrician on 1st day check, baby had an imperforated anus which had not been noticed on initial examination after delivery.”
Imperforate anus is the absence of a normal anal opening. It is a congenital abnormality and the diagnosis is usually made shortly after birth by a routine physical examination. Imperforate anus occurs in about 1 in 5,000 births and the cause is unknown.
Following a trigger incident, where a baby died of a perforated gut and peritonitis, a search of the National Reporting and Learning System (NRLS) identified 29 incidents related to delayed or missed diagnosis of imperforate anus over a three year period (January 2008 to December 2010).
Five of the babies had been discharged home with an undiagnosed imperforate anus. One baby was only diagnosed at 10 days of age as she had a vaginal fistula through which the meconium was being passed.
Imperforate anus can be difficult to diagnose. All of the 29 incidents involved babies that should have had an initial new born examination. However the abnormality was only found on subsequent checks, when parents drew it to the attention of clinicians or when the baby showed signs of obstruction.
This Signal should be brought to the attention of midwives and paediatricians to alert them to the importance of checking patency of the anus in newborn babies at the initial examination at birth and any subsequent physical examination. In accordance with the NICE postnatal guidelines
, emergency action should be taken if a baby fails to pass meconium in the first 24 hours after birth.
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with information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.