We report the case of a child, who accidentally received breast milk intravenously in the newborn period while being treated for duodenal atresia.

The child presented to us on day 2 of life with complaints of bilious vomiting. An abdominal X-ray showed a double-bubble sign and a diagnosis of duodenal atresia was made. Duodenodoudenostomy with a feeding jejunostomy using an infant feeding tube was done. Post operatively, breast milk was accidentally connected to the intravenous cannula instead of the jejunostomy tube on day 5 and the baby received about 75 mL of milk intravenously. The child developed severe Acinetobacter septicemia with shock following this. The episode was luckily non- fatal and the child was discharged after one month of ICU care.

This case brings to light an unusual but potentially fatal nursing mishap. The mishap occurred because the feeding lines are compatible with intravenous cannula. It is possible to prevent these rare accidents by using connection adaptors for tubes used for feeding purposes which are incompatible with intravenous cannula, like in the west. Recently in the developed countries where total parenteral nutrition is freely available, many pediatric surgical units have given up the practice of doing a feeding jejunostomy in cases of duodenal atresia(1). But since early enteral nutrition is still the most viable option in our country, additional care should be taken to prevent such accidents. We also stress on the importance of vigilant nursing care in neonatal units where, awareness of such accidents and supervision of nursing activities would prevent such life-threatening accidents.

V. Vanitha,
K.L. Narasimhan,
Department of Pediatric Surgery,
PGIMER, Chandigarh, India.

1. Upadhyay V, Sakalkale R, Parashar K, Mitra SK, Buick RG, Gornall P, et al. Duodenal atresia: a comparison of three modes of treatment. Eur J Pediatr Surg 1996, 6: 75-77.