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Pediatric Tracheoesophageal Fistula and Esophageal Atresia

Tracheoesophageal fistula is an abnormal connection in one or more places between the esophagus (the tube that leads from the throat to the stomach) and the trachea (the tube that leads from the throat to the windpipe and lungs). Normally, the esophagus and the trachea are two separate tubes that are not connected.

Tracheoesophageal fistula is also known as TE fistula or simply TEF.

TE fistula is a birth defect, which occurs in 1 in 5,000 births, and occurs as a fetus is forming in its mother's uterus.

When a baby with a TE fistula swallows, the liquid can pass through the abnormal connection between the esophagus and the trachea. When this happens, liquid gets into the baby's lungs. This can cause pneumonia and other problems.

What is esophageal atresia?

TE fistula often occurs with another birth defect known as esophageal atresia. The esophagus is a tube that leads from the throat to the stomach. With esophageal atresia, the esophagus does not form properly while the fetus is developing before birth, resulting in two segments; one part that connects to the throat, and the other part that connects to the stomach. However, the two segments do not connect to each other.

Since the esophagus is in two segments, liquid that a baby swallows cannot pass normally through the esophagus and reach the stomach. Milk and other fluids cannot be digested if the esophagus does not connect to the stomach.

What causes tracheoesophageal fistula and esophageal atresia?

As a fetus is growing and developing in its mother's uterus before birth, different organ systems are developing and maturing. The trachea and the esophagus begin developing as one single tube. At about four to eight weeks after conception, a wall forms between the fetus' esophagus and trachea to separate them into two distinct tubes. If this wall does not form properly, TE fistula and/or esophageal atresia can occur.

Which babies develop tracheoesophageal fistula or esophageal atresia?

These two conditions are not believed to be inherited. However, they are often seen when babies have other birth defects, such as:

  • Trisomy 13, 18, or 21
  • Other digestive tract problems (such as diaphragmatic hernia, duodenal atresia, or imperforate anus)
  • Heart problems (such as ventricular septal defect, tetralogy of Fallot, or patent ductus arteriosus)
  • Kidney and urinary tract problems (such as horseshoe or polycystic kidney, absent kidney, or hypospadias)
  • Muscular or skeletal problems
  • VACTERL syndrome (which involves Vertebral, Anal, Cardiac, TE fistula, Renal, and Limb abnormalities)

Approximately one-half of all babies with TE fistula or esophageal atresia have another birth defect.

Symptoms of TE fistula or esophageal atresia:

The symptoms of TE fistula or esophageal atresia are usually noted very soon after birth. The following are the most common symptoms of TE fistula or esophageal atresia. However, each child may experience symptoms differently. Symptoms may include the following:

  • Frothy, white bubbles in the mouth
  • Coughing or choking when feeding
  • Vomiting
  • Blue color of the skin (cyanosis), especially when the baby is feeding
  • Difficulty breathing
  • Very round, full abdomen

Other congenital malformations might be present, such as the ones mentioned in the previous section.

Symptoms of TE fistula or esophageal atresia may resemble other conditions or medical problems. It is important to talk with your child’s medical team to receive the right diagnosis.

Diagnosing TE fistula:

Along with a physical examination and medical history, imaging studies are usually done to evaluate whether a baby has TE fistula and/or esophageal atresia. X-rays are taken to look at the chest and abdomen.

A small tube may also be placed into the mouth or nose and then guided into the esophagus. With esophageal atresia, the tube usually cannot be inserted very far into the esophagus. The tube's position in the esophagus can also be seen with the X-ray.

Treatment for TE fistula or esophageal atresia:

If your baby has TE fistula or esophageal atresia, he or she will need surgery to fix the problem. The type of surgery depends on the following:

  • Type of abnormality
  • Overall health of the baby and medical history
  • Opinion of the surgeon and other healthcare providers involved in the baby's care
  • Expectations for the course of the condition
  • Parents’ opinion and preference

When TE fistula is repaired, the connection between the esophagus and the trachea is closed in surgery. Repair of esophageal atresia depends on how close the two sections of esophagus are to each other. Sometimes esophageal atresia requires more than one surgery. Your baby's pediatric surgeon and other healthcare providers will decide when it is best to do the operations based on your baby's condition and the type of problem.

The repair of esophageal atresia or tracheoesophageal fistula with esophageal atresia can be accomplished with either open (thoracotomy) or minimally invasive surgical approaches. Depending upon the length of the gap between the upper and lower portions of the discontinuous esophagus and the experience of the pediatric surgeon, the esophagus may be reconnected using the minimally invasive approach in many cases. Sometimes multiple procedures are necessary to connect the upper and lower esophageal segments.

Could my child have problems in the future?

Some children born with esophageal atresia have long-term problems.

Swallowing food or liquids may be difficult due to problems with the normal movement of foods and liquids down the esophagus (peristalsis), and scarring that can occur in the esophagus after surgery as the wounds heal, which can partially block the passage of foods.

Sometimes, a narrowed esophagus can be widened or dilated with a special procedure done while the child is under general anesthesia. In other cases, another operation may be necessary to open up the esophagus so food can pass to the stomach properly.

About one-half of children who had esophageal atresia repaired will have problems with GERD, or gastrointestinal reflux disease. GERD causes acid to move up into the esophagus from the stomach. When acid moves from the stomach into the esophagus, it causes a burning or painful feeling known as heartburn. GERD can usually be treated with medications or by a minimally invasive surgical antireflux procedure known as a fundoplication.

Children's Team

Children's Team


Ian Leibowitz

Ian Leibowitz

Division Chief, Gastroenterology, Hepatology and Nutrition Services
Vahe Badalyan

Vahe Badalyan

Director, Celiac Disease Program
Children's National Hospital

Megan Calvert

Nurse Practitioner
Specialist, Feeding Disorder Program
Dr. Shayna Coburn

Shayna Coburn

Psychosocial Health Director, Celiac Disease Program
Lori Stern

Lori Stern

Nurse Practitioner
Specialist, Feeding Disorder Program
Clarivet Torres

Clarivet Torres

Director, Intestinal Rehabilitation Program
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