Infants who consistently choke and cough or become cyanotic with feeding should be evaluated for the presence of

• A. Achalasia
• B. Tracheoesophageal fistula
• C. Pyloric stenosis
• D. Lactose intolerance

Answer: (B)

Choking, coughing, or cyanosis during feeds in an infant points to an airway–esophageal abnormality that allows material to enter the airway during swallowing. The best explanation is a tracheoesophageal fistula with esophageal atresia, a congenital defect in which the esophagus doesn’t form a continuous passage and an abnormal connection exists between the trachea and esophagus. When the infant tries to feed, saliva or milk can pass through this fistula into the airway, causing immediate coughing or choking and sometimes turning the infant blue. This pattern of symptoms is why TE fistula is the most likely diagnosis and why urgent evaluation and surgical repair are required.

In contrast, pyloric stenosis causes progressive nonbilious projectile vomiting several weeks after birth with dehydration, not acute choking during feeds. Achalasia in newborns is uncommon and would present with difficulties swallowing and regurgitation but not the classic feeding-associated choking/cyanosis. Lactose intolerance leads to GI symptoms like diarrhea and bloating, not airway symptoms during feeding.