What additional evaluation is indicated in a 3-hour-old girl with excessive coughing, coarse breath sounds, and a nasogastric tube encountering resistance at 10 cm, suggesting esophageal atresia (EA) or tracheoesophageal fistula (TEF)?

From the Research

The most appropriate additional evaluation for this newborn girl is renal ultrasonography (option D). This patient's presentation strongly suggests esophageal atresia, as evidenced by the coughing during feeding and the inability to pass the nasogastric tube beyond 10 cm with radiographic confirmation of the tube coiling in the upper esophagus. Esophageal atresia is commonly associated with other congenital anomalies, particularly those of the VACTERL association (Vertebral defects, Anal atresia, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities) 1. Given this association, renal ultrasonography is indicated to evaluate for potential kidney malformations that may accompany esophageal atresia. Approximately 30-50% of infants with esophageal atresia have associated renal anomalies, which can include renal agenesis, horseshoe kidney, or polycystic kidneys 2. Early detection of these anomalies is important for comprehensive management of the infant. The other options are not immediately indicated based on the clinical presentation, which specifically points to esophageal atresia with possible associated anomalies.

Some key points to consider in the management of esophageal atresia include:

• The importance of early diagnosis and surgical intervention to prevent long-term morbidity 3
• The need for a multidisciplinary approach to care, including pediatric surgery, neonatology, and other specialties 4
• The potential for associated anomalies, such as cardiac defects and vertebral anomalies, which must be evaluated and managed appropriately 1
• The use of renal ultrasonography as a key diagnostic tool in evaluating for associated renal anomalies 2

In terms of the specific evaluation of tracheoesophageal fistula, a contrast material swallow (CS) is often the examination of choice, with a pull-back tube esophagogram (PBTE) reserved for patients who are intubated or at significant risk of aspiration 5. However, in this case, the primary concern is the evaluation of potential associated anomalies, rather than the diagnosis of tracheoesophageal fistula itself.

Overall, the clinical presentation of this newborn girl suggests esophageal atresia, and renal ultrasonography is the most appropriate additional evaluation to assess for potential associated renal anomalies.