The role of radiocontrast agents in the treatment of meconium-related intestinal obstruction in preterm neonates with extremely low birth weight: a review

Improvements in intensive care for extremely preterm, extremely low birth weight (ELBW) infants have significantly improved their survival rates but have also increased the incidence of meconium-related intestinal obstruction. Despite the pathogenetic rationale for the use of water-soluble iodinated contrast agents (WSICA), optimal protocols for their use in ELBW infants remain controversial. This review aimed to summarize and critically evaluate the evidence on the use of WSICA for the diagnosis and treatment of this condition in ELBW neonates. We searched in PubMed, Scopus, Web of Science, the Cochrane Library, and eLibrary for the period January 2000 to December 2025. We included clinical trials of various designs, systematic reviews, and meta-analyses on very-low-birth-weight and extremely-low-birth-weight preterm neonates who received WSICA for meconium obstruction. The initial search identified 127 records; after abstract review and full-text screening, 40 were included in the final analysis. We analyzed the mechanisms of action of ionic (diatrizoate meglumine, sodium diatrizoate) and non-ionic (iopromide, iopamidol, iohexol) contrast agents, their administration protocols, efficacy, and tolerability. Conservative therapy with WSICA resolves obstruction in 48.6% to 100% of cases. This wide range reflects not method inconsistency but differences in selection criteria and cohort composition: the higher values were obtained with strict selection of patients with confirmed meconium-related obstruction, while the lower values came from cohorts that included exclusively ELBW infants with severe comorbidities. Factors consistently associated with conservative treatment failure include body weight < 700 g, onset after day 10 of life, and marked intestinal dilatation. Intestinal perforation occurs in 5%–9% of cases. Most such episodes are related not to the method itself but to protocol violations — administration of undiluted contrast, use of balloon catheters, and delayed treatment initiation. Direct comparison of Russian (48.6%–65%) and international (54.5%–100%) data is inappropriate due to differences in cohorts, protocols, and outcomes assessed. The use of WSICA is pathogenetically justified and can avoid surgery in a significant proportion of ELBW neonates. This review presents the mechanisms of action and comparative characteristics of WSICA, consistently reproducible factors for conservative treatment failure, and current approaches to minimizing complication risks. Priority areas for future research include prospective multicenter studies aimed at developing an international consensus, prognostic scales to stratify the risk of conservative treatment failure, and long-term neurodevelopmental follow-up.