Summary

Inadvertent knotting of infant feeding tubes used for clean intermittent catheterisation (CIC) is a rare complication in paediatric patients. The small flexible tubes used in infants if advanced too far into the bladder may form a knot as the bladder empties. Surgical intervention is required especially if it is lodged in the urethra. We present a case of a baby boy aged 4 months on CIC with a 6 Fr feeding tube, which required a meatotomy for removal. Education while instituting CIC must emphasise the length of catheter insertion, the chance of knotted catheter and steps to take if it occurs. A dedicated urotherapy nurse would be ideal.