Iatrogenic esophageal perforation in extremely preterm newborn with multiple comorbidities: case report and ethical considerations

Neonatal esophageal perforation (EP) is a rare but potentially life-threatening complication, particularly in extremely low birth weight (ELBW) infants exposed to repeated invasive procedures. Although conservative management has progressively improved survival rates, mortality remains significant among the most vulnerable neonates. Literature studies predominantly describe favorable outcomes, possibly underrepresenting early lethal cases and overlooking the ethical implications of iatrogenic injury in infants at the threshold of viability. We report a fatal case of iatrogenic EP in an ELBW preterm infant and discuss diagnostic challenges, management strategies, and ethical considerations. A male infant was born at 27 weeks’ gestation with severe intrauterine growth restriction and birth weight of 480 g. His clinical course was complicated by respiratory distress syndrome requiring prolonged mechanical ventilation, sepsis, patent ductus arteriosus, evolving bronchopulmonary dysplasia, pulmonary hypertension, hypertrophic cardiomyopathy, and periventricular leukomalacia. On day 24 of life, acute abdominal distension and clinical deterioration prompted radiographic and ultrasonographic evaluation. Imaging demonstrated malposition of the orogastric tube and right-sided pneumothorax, and subsequent mediastinal emphysema, confirming esophageal perforation. Conservative management was initiated, consisting of tube removal, nil per os, parenteral nutrition, broad-spectrum antibiotics, antifungal prophylaxis, respiratory and hemodynamic support, and pleural drainage. Despite timely recognition and adherence to recommended management strategies, the infant progressed to refractory multiorgan failure and died at one month of age. This case highlights the potentially fatal impact of EP in ELBW infants, in whom outcomes may be driven more by extreme prematurity and systemic instability than by the perforation itself. Bedside ultrasonography proved valuable for early detection and monitoring while limiting radiation exposure. Beyond clinical management, EP in critically ill preterm neonates raises complex ethical issues regarding proportionality of care, risk–benefit balance of invasive procedures, and transparent communication with families. Reporting severe and fatal cases is essential to improve awareness, refine preventive strategies, and foster ethically grounded decision-making in neonatal intensive care.