Easily missed, potentially fatal complication in an extremely preterm infant.

A baby girl was delivered by emergency caesarean section at 23+6 weeks gestation weighing 440 g. Apgar scores were 1, 3 and 4 at 1, 5 and 10 min, respectively. She was intubated and transferred to the neonatal intensive care unit. Umbilical arterial and venous lines and an orogastric tube (OGT) were inserted. On day 4 of life the OGT appeared to be outside of the gastrointestinal tract on X-ray. Feeds were held and contrast oesophagography confirmed suspicion of an oesophageal perforation. She was treated with intravenous metronidazole, gentamycin and amoxicillin and placed nil by mouth for 10 days. Resolution of the perforation was confirmed on repeat contrast study (day 10) and feeds were restarted with no further complications.