Risk of Necrotizing Enterocolitis (Nec) for Premature Baby

Risk of Necrotizing Enterocolitis (Nec) for Premature Baby

NECROTIZING ENTEROCOLITIS (NEC) is the most common acquired gastrointestinal emergency in the preterm low birth weight newborn. It is a result of an insult to the immature gut, characterized by varying degrees of mucosal or transmural necrosis. Mostly affects premature infants, NEC involves infection and inflammation that causes destruction of the bowel (intestine) or part of the bowel.


Babies with NEC may have a tender or tense abdomen, need more oxygen or higher ventilator settings, have blood in their bowel movements, or exhibit signs of apnea. An X-ray of the abdomen confirms the diagnosis. Necrotizing enterocolitis (NEC) is a serious intestinal illness in babies.

Premature babies have body systems that are more immature. As a result, they may have difficulty with blood and oxygen circulation, digestion, and fighting infection, thus, increasing their chances of developing NEC.In the most serious cases, this condition can be life-threatening.

As if the birth of a premature baby isn't stressful enough, there are a number of diseases premature babies can experience within the first weeks of life. Necrotizing enterocolitis (NEC) is one of them.Although NEC may develop in low-risk newborns, most cases occur in premature babies. NEC is more common in babies weighing less than 1,500 grams (3 pounds, 4 ounces).

NEC is an acute intestinal necrosis syndrome of unknown etiology and prematurity is the single greatest risk factor. The causes are not well defined and may be resulting from complex interactions between mucosal injury secondary to a variety of factors, including ischemia (splanchnic vesoconstriction), luminal substrate (high osmolar, formula, large volume, rapid enteral feeding), infection and inflammatory mediators (cytokines, endotoxins, platelet activating factor), and poor host protective mechanisms in response to injury.

Those with a higher risk for this condition include:

Predisposing factors:

No single factor has been established as the cause of NEC. It is now thought that NEC is the result of a combination of several factors. The two consistent findings are prematurity and feedings. The premature intestine reacts abnormally and develops an acute inflammatory response to feedings leading to intestinal necrosis (death). Some postnatal issues including heart abnormalities, obstruction of circulation in the bowel, infection or gastroschisis are also associated with NEC. Others are:

  1. Early onset of feed with hyperosmolar milk.
  2. Perinatal asphyxia.
  3. Polycythemia.
  4. Umbilical vessel catheterization.

Pathogenesis of the disease is multifactorial, related to previous intestinal ischemia, bacterial or viral infection and immunologic immaturity of the gut.

Clinical Features:

Onset usually occurs in the first 2 weeks. Meconium is passed normally, and the first signs are abdominal distension with gastric retention. Other signs include vomiting or increased gastric residuals, bloody stool, abdominal tenderness, temperature instability, apnea and bradycardia.

Clinical manifestations: A triad of abdominal distension, blood in stool and gastric residuals should be suspected of necrotizing enterocolitis. The clinical features are variable, and the signs and symptoms may not be specific. The infant may develop feeding intolerance with retention of feeding, abdominal distension, temperature instability and lethargy.

Apnea may be a prominent feature. Bilious vomiting, acidosis and DIC may be present. There may be ileus, abdominal wall erythema, abnormal mass ,ascites and bloody stool.Pneumatosis intestinalis in abdominal x-ray is the hallmark of diagnosis. Besides, the x-ray may reveal bowel wall edema, intestinal dilatation, portal or hepatic venous air, pneumoperitonium.
The differential diagnosis includes- feeding intolerance, infectious enterocolitis, pneumonia and sepsis, acute abdomen due to any surgical cause.

Treatment /Management :

This includes immediate medical management and surgical intervention if indicated.

A. Medical Treatment :

  1. Cessation of feeding.Nothing per oral with gastrointestinal decompression.
  2. Decompression of gut by nasogastric tube.In case of bleeding diathesis- exchange transfusion or specific factor replacement is necessary.
  3. Maintenance of oxygenation.In case of shock- maintain blood pressure and urine output with fluids, fresh/ frozen plasma, whole blood; and dopamine, steroids.
  4. IV fluid to replace third-space GIT losses.Supportive care- maintains adequate hematocrit, PH, PO2, PCO2, and electrolyte
  5. balance and mechanical ventilation.
  6. Nutrition: Once stabilized begin IV alimentation followed by slow gradual introduction of enteral feeding.
  7. Broad spectrum antibiotics e.g. a combination which cover gram positive and negative organisms including anaerobic organism such as ampicillin,gentamycin and metronidazole, the regimen may changed later according to the culture results.
  8. Fresh blood transfusion.In case of bleeding diathesis- exchange transfusion or specific factor
  9. replacement is necessary.
  10. Close monitoring of vital signs, laboratory data (Blood gas, WBC count. Platelet count and X-ray).

B. Surgical treatment :

Necrotic bowel is removed and if the infant is in good condition primary anastomosis can be carried out, but if the infant's condition is parlous during the laparotomy, excise affected bowel, defunction with a proximal ostomy and do a repeat operation some week later to replace the bowel in continuity.

Two surgical procedures, one invasive and the other much less so, for premature infants with intestinal perforation due to necrotizing enterocolitis (NEC) produce virtually identical results, according to a Yale School of Medicine study published today in the New England Journal of Medicine.

The standard surgical procedure in such cases has been a laparotomy with resection of all necrotic intestine and intestinal diversion. This approach derives from experience in adults, in whom it would be considered unthinkable to leave necrotic
intestine in place.

Comments

about this diease

My son just passed away yesterday from this diease and it happened in the matter of hours and i just dont understand why. he was born at 25 weeks and he was 33 weeks gestation when he died..the doctors said it usually happens early in life..they just understand why it happen so late in his life.i feel like i need more answers

my baby

my baby riley was born at 29 plus 6 days he was very healthy and doing extremly well untill he was 7 days old he got an infection in his bowel called necrotizing enterocolitis he got very ill very fast he was transfered to bristol hospital the same day once there the doctors spent all night trying to stablize his condition the next day he was taken into surgery so the doctors could see how bad his condition was and try to repair his bowel but there was nothing they could do for my little angel as the infection had killed all of his bowel my baby boy died at 8 days old if there is anyone out there that has been in a simular situation please get in touch

my twins were born at 28

my twins were born at 28 weeks, the stronger of the two got sick 12 days in. at 10:00 in the morning he was looking sick, by two his bowels perfarated and by 7:00 he had been taken by lifeflight and had a surgery where the removed some of his large intestine and his appendix, and they put his small into a silo so we could watch it to see if it would survive, by morning his entire intestine had died and we had to pull the vent. nothing else was wrong with our little sam, but nec took him from us and what hurts is no one know what causes nec its just a guess, the most common factors is that its a premie and feeding

I lost my son Liam to

I lost my son Liam to NEC.
I'm so sorry for your loss. I had a similar experience, my son Liam passed away on Nov 11, 2009 after developing NEC (necrotizing enterocolitis). He was born at 26 weeks plus 1, weighing 505 grams. He was 24 days old when he developed NEC. His sugars had been up and down the week prior and he had started to need more oxygen and had developed apneas and bradys for 2 days prior to his diagnosis. He had become quite pale and I had requested a blood transfusion which he received the day prior to passing away. He had also just had a supplement added to his breast milk feeds the day prior to his passing. Otherwise he was healthy and finally starting to grow and was in good form, he was active and alert. The NEC diagnosis came as a shock. My 1st call from the doctor came at 9:00pm on Nov 10th to say he 'didn't look good' and they were closely monitoring him. The next call came at 12:30am telling me to come to the hospital as he had been diagnosed with NEC and might need surgery. When I arrived at the hospital I was told Liam had a perforated bowel. He was then transferred at 1:30am for emergency surgery where they placed a drain. He never recovered and that morning his vitals started to crash, they could not get his heart rate back up and he ended up passing away in my arms around 8:20am on Nov 11th.

I just hope in future they can diagnosis earlier or have more success treating babies who have developed NEC.

My little angel Liam will be missed but never forgotten.

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