Bananas and neonatal gastric perforation.

Sir,

Neonatal gastric perforation (NGP) remains a dreaded problem, with most centers reporting survival rates of 30–50% only. We present two neonates from a remote, mountainous area in India who suffered a rupture of the stomach due to the local practice of feeding bananas to the neonates from the third day of life.

The two babies of ages 7 and 21 days presented to the emergency department with similar history of poor feeding, lethargy and fever for 3 days and 1 week, respectively. Both babies had been born at home by normal vaginal delivery and had passed stools normally after birth. Both babies have been fed bananas from the second day of life, as is the local custom. The initial symptom was abdominal distension. On examination, the babies were drowsy with tachypnea, tachycardia, poor peripheral perfusion and massive abdominal distension. After initial resuscitation, both the patients were taken up for surgery. At laparotomy, the stomach was hugely distended with a congealed mass of banana mixed with milk. In both cases, it had ruptured along the greater curvature with the rent beginning just below the gastroesophageal junction and the contents had contaminated the entire peritoneal cavity. In the second neonate, the edges of the stomach rent had become adherent to the abdominal wall. The rents were closed primarily. The second baby did not improve and expired a few hours after the operation. The first baby recovered and is well at 3 months follow-up.

NGP is a surgical emergency that still carries a high mortality. Classically, three etiological mechanisms have been proposed – traumatic, ischemic and spontaneous. However, most perforations can be attributed to a particular cause, making spontaneous perforation a rare diagnosis.[1] The most common cause is iatrogenic trauma due to vigorous orogastric or nasogastric tube placement, bag and mask resuscitaton, nasal continuous positive airway pressure or mechanical ventilation in the intensive care setting.[2] Prematurity, chorioamnionitis in the mother, low birth weight, sepsis, neonatal asphyxia, gastric stress ulcers, respiratory distress syndrome, tracheo-esophageal fistula, necrotising enterocolitis, meconium plug and postnatal steroid treatment for bronchopulmonary dysplasia or brain edema have all been found to be associated with neonatal gastric perforation.[23] Congenital defects in the muscular wall of the stomach are still being evaluated as a risk factor for neonatal gastric perforation. A study by Ohshiro et al. showed that neonates who had a gastric perforation with no identifiable cause either had a complete lack of the interstitial cells of Cajal (ICC), the pacemakers of the intestine, or had fewer ICC than controls with an abnormal distribution.[4]

The cultural practice of feeding bananas to neonates has existed in Meghalaya, a hill state in the North East of India, for many generations, which may be contributing to the reported infant mortality rate of 56 per thousand live births.[5] Both the mothers claimed to have followed the same practice of feeding bananas at 3 days to all their other previous children with no complications.

Community health initiatives to underline the importance of breast milk as the only nutrition required for neonates are underway to change this unusual practice, and we hope that the reinforcement of this practice will reduce the unnecessary morbidity and mortality associated with it.