A Novel Rectal Propranolol Strategy in Neonatal Supraventricular Tachycardia Complicated by Surgical Necrotizing Enterocolitis

Objective: Surgical necrotizing enterocolitis (NEC, Bell Stage 3B) complicating neonatal supraventricular tachycardia (SVT) is exceedingly rare. We describe a novel per-rectal propranolol strategy to maintain antiarrhythmic prophylaxis during mandatory nil per oral (NPO) status imposed by NEC. Study Design: Single case report at a tertiary neonatal unit in Western India. Results: A 35-week neonate with antenatal fetal tachyarrhythmia (>300 bpm) developed postnatal SVT at 6 hours of life (280–300 bpm), requiring adenosine cardioversion and oral propranolol. On day of life (DOL) 4, haematochezia, abdominal distension, and portal venous gas indicated Bell Stage 3A NEC, mandating NPO status. With enteral routes contraindicated, propranolol was continued per rectum, to our knowledge the first reported neonatal antiarrhythmic use of this route. Deterioration to pneumoperitoneum by DOL 8 necessitated laparotomy with jejuno-jejunal and ileo-caecal resection and anastomosis. No SVT recurred during NPO. The infant was discharged on DOL 25 on oral propranolol. Conclusion: This first Indian report of SVT-associated surgical NEC highlights two novelties: Bell Stage 3B NEC requiring surgery and per-rectal propranolol as a novel antiarrhythmic bridge during NPO. Clinicians should maintain vigilance for NEC in neonates with SVT regardless of haemodynamic stability, and consider the rectal route for propranolol when NPO.