When a Baby's Intestine Twists: New Answers About Why It Happens and What Can Be Done

A plain-language guide to three 2026 studies from Germany, Sweden and the United States on intestinal malrotation and midgut volvulus

Sometimes a baby's intestine twists on itself and cuts off its own blood supply — an emergency called a midgut volvulus. It is rare, it usually strikes babies who seemed perfectly healthy, and until recently almost nothing was known about why it happens to one child and not another. Three studies published in 2026, from Germany, Sweden and the United States, have begun to change that.

The problem that has worried doctors for decades

To understand the twist, it helps to picture how the intestine is built. Early in pregnancy the gut is a straight tube. Between about the fourth and twelfth weeks it grows so fast that it temporarily loops out into the umbilical cord, turns a corner, comes back into the abdomen, and then anchors itself along a long diagonal line at the back of the belly [1]. That long anchor line is what keeps the intestine stable for the rest of a person's life.

In a small number of babies, the turn does not finish. The intestine still works, but instead of a long anchor it hangs from a narrow stalk — a bit like a mobile hanging from a single thread rather than a wide frame. Doctors call this intestinal malrotation. Most of the time it causes no trouble at all; some adults discover they have it only when they are scanned for something else. But a narrow stalk can rotate, and if it does, it pinches shut the one artery that feeds most of the small intestine. That is a midgut volvulus, and without an operation within hours the bowel can die.

For decades this left families and clinicians in a difficult position. The warning sign is green (bile-stained) vomiting in a baby, which is why every paediatric textbook says that a vomiting baby with green vomit must be investigated urgently. But green vomiting has many causes, most of them harmless, and the babies who do have a volvulus often look well until quite late. Hospitals have studied their own records repeatedly to find where time is lost. One Canadian children's hospital reviewed 30 children treated for midgut volvulus between 2015 and 2022; 28 of them survived, two were left with a shortened intestine, and the team concluded that the delays worth attacking were the ones before the operation — the wait for assessment, for a scan, for a surgeon [2]. Another long-running question is simply who gets it. Malrotation is not only a newborn problem; in a Swedish group of children with confirmed malrotation, some were diagnosed as babies and others not until school age, and about half had other birth differences as well [3]. For children with no other differences at all, the answer to "why did this happen to my baby?" has always been, honestly, that nobody knew.

Study one: a twist seen before birth does not always mean an emergency delivery

The first of the 2026 studies comes from the University Children's Hospital in Tübingen, Germany, where the prenatal ultrasound unit, the newborn intensive care unit, the paediatric surgery department and an intestinal rehabilitation centre all work together [4]. The team looked back at seventeen years of their own patients — every child treated for a midgut volvulus between 2005 and 2022 — and ended up with 45 children to study. Thirty-eight of them were diagnosed after birth and taken straight to the operating theatre. Seven were spotted before birth, on pregnancy ultrasound scans.

Those seven fetuses are the interesting part. In all seven, the ultrasound showed swollen loops of bowel and a characteristic pattern called the "whirlpool" or "coffee bean" sign, which is the twisted blood vessels seen end-on. Five of the seven showed additional worrying signs — abnormal blood-flow measurements, reduced movements, or an abnormal heart-rate trace — and those five babies were delivered urgently by caesarean section and operated on straight away. All five survived and all are now feeding normally.

The other two were different. Both were found very early, at around 24 and 25 weeks of pregnancy, which is far too early for a safe delivery, and neither showed any sign that the baby was in distress. The team decided to watch rather than deliver. In both pregnancies the twist untwisted on its own. The first signs of improvement appeared 18 days and 38 days after the diagnosis, and the scans were completely normal 24 days and 77 days after diagnosis. Both babies were born at full term at healthy weights — 2,700 g and 3,060 g, or about 6 lb and 6 lb 12 oz — fed well, never needed an operation, and went home six days after birth.

The Tübingen team is careful to say that two babies cannot become a rule, and they are right. But it is the first clear demonstration that a twist seen before birth is not automatically a reason to deliver a very premature baby. They also found something unexpected: none of the seven fetuses with a prenatal twist actually had malrotation, whereas 23 of the 38 babies diagnosed after birth did. A twist before birth appears to be a somewhat different problem from the classic one. And two of the five fetuses who needed surgery turned out to have cystic fibrosis, picked up on the routine newborn screening heel-prick test — a reminder that a bowel problem before birth can be the first clue to something else entirely.

Reassuringly, none of the seven babies diagnosed before birth died. The deaths in this study — five out of the 38 diagnosed after birth — were all in babies who had been born extremely prematurely, at around 25 weeks and weighing about 500 g. Other researchers who pooled all the published cases of volvulus before birth have found broadly similar results, with around eight in ten babies surviving [5].

Studies two and three: reading the genes

The other two studies asked the "why did this happen?" question directly, by reading children's DNA.

A team at Karolinska University Hospital in Stockholm, Sweden, selected ten children who had malrotation with a twist early in life and absolutely nothing else wrong — no other birth differences, no syndrome — and read their entire genetic code, focusing on 442 genes already suspected of being involved in how the gut develops [6]. In three of the ten children they found rare changes, and remarkably, all three pointed at the same biological pathway: the set of molecular switches (involving genes named TTC7A, ROCK2 and LIMK2) that tell developing tissue how to bend, stretch and turn. In other words, the genes involved were not random — they were the genes that run the machinery of rotation itself.

One detail from that study is worth dwelling on. In the family of the first child, the genetic change had come from his mother. When doctors went back and looked again at scans she had had years earlier, they found she had a mild version of the same anatomical difference — one that had never caused her any symptoms and that nobody had noticed. This suggests that malrotation may run in families more often than anyone realises, simply because relatives with mild forms are never scanned.

The third study, from the Center for Advanced Intestinal Rehabilitation at Boston Children's Hospital in the United States, came at the question from the opposite end [7]. Instead of choosing children with a mild course, the team chose 21 children who had been left with intestinal failure — meaning so little intestine remained after surgery that they needed nutrition through a vein. They read the genetic code of each child and of both parents, which makes it possible to spot changes that appeared new in the child. They found candidate changes in four different genes, with no single gene shared by more than three children, and none of them the same genes the Swedish team had found.

That sounds like a disappointment, but it is itself an answer of a kind. Two careful studies looking at the same condition found no common genetic cause, which strongly suggests there isn't one. Malrotation is probably not a single genetic disease; it is more likely to be many rare causes, or a combination of genetic tendency and chance events during pregnancy. Where malrotation comes as part of a wider syndrome, the genetics are already much better understood [8].

What this means for families

If your baby has been diagnosed with a midgut volvulus after birth, nothing here changes the urgency: the operation is the treatment, and speed matters. What these studies add is context for the conversations that come afterwards.

If a twist is found on a pregnancy scan, this research supports asking for a joint discussion involving the obstetric, newborn and surgical teams rather than assuming immediate delivery is the only path. How far along the pregnancy is, and whether the baby shows any sign of distress, are the two things that guided decisions in the Tübingen series. Scanning technology continues to improve, with ultrasound now accepted as a reasonable first test after birth [9] and magnetic resonance imaging being studied as an addition to ultrasound before birth [10].

If you are asking whether this could happen to another child, the fair answer is that genetics probably plays a part, that it is unlikely to be a simple inherited condition, and that testing outside a research study would not currently change anything about your family's care. It is also worth knowing that a family history described as "clear" may not be, since mild forms are usually invisible.

What researchers are working on next

Three lines of work follow. Doctors want to know how reliably ordinary ultrasound — not just ultrasound performed by specialist children's radiologists — can find a twist quickly, because that is where minutes are won or lost. Obstetric and surgical teams want to build a shared international register of babies diagnosed before birth, since no single hospital sees enough cases to know which of them can safely be watched. And geneticists want to repeat the Stockholm and Boston studies across many hospitals at once, with enough families to turn interesting candidate genes into real answers. Separately, surgeons continue to compare keyhole and open versions of the corrective operation; a 2026 review combined 18 studies covering 3,479 children to weigh the two approaches [11].

None of this is finished work. But for the first time, the question families have always asked — why my baby? — has research pointing towards an answer rather than a shrug.

References

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  2. Filion L, Beaunoyer M, Miron MC, et al. Infant malrotation with midgut volvulus: a retrospective review of clinical presentation and delays in care at a Canadian tertiary paediatric centre. Paediatr Child Health. 2025;30(6):453-458. doi:10.1093/pch/pxaf042 ↩
  3. Salehi Karlslätt K, Husberg B, Ullberg U, et al. Intestinal malrotation in children: clinical presentation and outcomes. Eur J Pediatr Surg. 2024;34(3):228-235. doi:10.1055/s-0043-1764239 ↩
  4. Holweg M, Lieber J, Kagan KO, et al. Fetal volvulus: is emergency surgery the only option? — a single-center case series and management considerations. Arch Gynecol Obstet. 2026;313(1):158. doi:10.1007/s00404-025-08256-4 ↩
  5. Acer-Demir T, Şahin-Uysal N. Intrauterine volvulus: systemic review of the literature with pooled analysis. J Perinatol. 2024;44(11):1543-1551. doi:10.1038/s41372-024-01984-6 ↩
  6. Salehi Karlslätt K, Pettersson M, Lagerstedt-Robinson K, et al. Rare variants in TTC7A, ROCK2 and LIMK2 suggest a role for the ROCK-signaling pathway in isolated intestinal malrotation. Pediatr Surg Int. 2026;42(1):241. doi:10.1007/s00383-026-06442-2 ↩
  7. Salazar JA, Rockowitz S, French CE, et al. Genetic sequencing of children with malrotation and midgut volvulus: a cross-sectional study. JPGN Rep. 2026. doi:10.1002/jpr3.70230 ↩
  8. Martin V, Shaw-Smith C. Review of genetic factors in intestinal malrotation. Pediatr Surg Int. 2010;26(8):769-781. doi:10.1007/s00383-010-2622-5 ↩
  9. Nguyen HTN, Navarro OM, Bloom DA, et al. Ultrasound for midgut malrotation and midgut volvulus: AJR expert panel narrative review. AJR Am J Roentgenol. 2022;218(6):931-939. doi:10.2214/AJR.21.27242 ↩
  10. Kou C, Song Y, Gao D, et al. Prenatal diagnosis of midgut volvulus by fetal MRI: a retrospective study. Front Pediatr. 2024;12:1442866. doi:10.3389/fped.2024.1442866 ↩
  11. Lang Y, Chen Q, Wu M, et al. Laparoscopic vs open Ladd's procedure for intestinal malrotation in infants and children: a systematic review and meta-analysis. Surg Innov. 2026:15533506261460156. doi:10.1177/15533506261460156 ↩