Pneumoperitoneum m a newborn is commonly caused by necrotising enterocolitis or spontaneous gastric perforation. Occasionally outbreak of pneumoperitoneum has been reported in neonatal units due to iatrogenic rectal injuries(1). We have encountered two cases of iatrogenic rectal perforation. Case 1 Was two days old male , child of 2 kg weight admitted in Neonatal Intensive Care Unit with abdominal distension and non-passage of meconium for 24 h. Baby was put on intravenous fluids, antibiotics and nasogastric tube aspiration. The TLC was 6,000 Cu mm while C-reactive protein and blood culture were negative. Saline enemas with rubber catheter were given thrice by nursing staff for decompressing the abdomen. Skiagram of abdomen revealed pneumoperitoneum. Exploratory laparotomy showed 1.5 x 1.5 cm size perforation in the anterior wall of rectum just above peritoneal reflection and rest of bowel was normal. End colostomy was done with closure of rectal stump at the site of perforation. Bowel continuity was restored after six months and baby is now well. Histopathological examination revealed an organizing fibrinous serositis and ganglion cells were present. Case 2 was 19 days female child of 2,.2 kg weight admitted with abdominal distension and constipation of ten days duration. The baby was initially treated by general practitioner by intravenous fluids, antibiotics and repeated enemas for a period of 5 days. Her TLC was 18,000 cu mm, C reactive protein was positive and blood culture grew Gram negative bacilli. Abdomen was grossly distended. Skiagram of abdomen revealed sacral agenesis and bowel gas pattern was normal. Perineal area was grossly infected. Skin over the natal cleft necrosed off in a few days and underlying rectum with perforation was visible. Transverse colostomy was done and' the patient is on regular follow up for dressings.

Rectal perforation in newborns usually results from inadvertent insertion of rectal thermometer or enema tube. The suggested mechanisms of injury by enemas are(2): (i) trauma from tip of enema tube and (ii) increased hydrostatic pressure. Perforation from enema tip is caused when inserted by unskilled attendant or during self insertion(3). Hydrostatic pressure as low as 50 mm Hg has been reported to cause rectal perforation in adults(4). In the above patients, the probable reason for rectal perforation seems to be raised hydrostatic pressure because saline enemas were given with soft catheter with the help of syringe. Enema perforations have been classified into five types(5) namely, anal perforation, submucosal perforation, extraperitoneal perforation, intraperitoneal perforation and perforation into adjacent organs. Extra-peritoneal perforation can be successfully treated nonoperatively while intraperitoneal perforation needs operative intervention. To prevent the occurrence of rectal perforation it is recommended that enemas should be minimized in neonatal units and routine rectal temperature recording should not be done. All nursing and medical personnel treating newborns must be aware of the potential hazards of enemas.

Yogender Singh,
Narinder Singh,
K.L. Narasimhan,
S.K. Mitra,
Department of Pediatric Surgery,
Postgraduate Institute of Medical
Education and Research,
Chandigarh 160012,
India.