Necrotizing enterocolitis

Last updated
Necrotizing enterocolitis
Specialty Pediatrics, gastroenterology, neonatology
Symptoms Poor feeding, bloating, decreased activity, vomiting of bile [1]
Complications Short-gut syndrome, intestinal strictures, developmental delay [2]
CausesUnclear [1]
Risk factors Preterm birth, congenital heart disease, birth asphyxia, exchange transfusion, prolonged rupture of membranes [1]
Differential diagnosis Sepsis, anal fissure, infectious enterocolitis, Hirschsprung disease [2] [3]
Prevention Breast milk, probiotics. [2]
Treatment Bowel rest, nasogastric tube, antibiotics, surgery [2]
Prognosis Risk of death 25% [1]

Necrotizing enterocolitis (NEC) is an intestinal disease that affects premature or very low birth weight infants. [4] [1] Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, vomiting of bile, multi-organ failure, and potentially death. [1] [2]

Contents

The exact cause is unclear. [1] However, several risk factors have been identified. Consistently described risk factors include formula feeding, intestinal dysbiosis, low birth weight, and prematurity. [5] Maternal factors such as chorioamnionitis, cocaine abuse, intrauterine growth restriction, intrahepatic cholestasis during pregnancy, increased body mass index, lack of prenatal steroids, mode of delivery, placental abruption, pre-eclampsia, and smoking have not been consistently implicated with the development of NEC. [6] [7] [8] [9] [10] Other risk factors potentially implicated include congenital heart disease, birth asphyxia, exchange transfusion, and prelabor rupture of membranes. [1] The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. [2] Diagnosis is based on symptoms and confirmed with medical imaging. [1]

Prevention includes the use of breast milk and probiotics. [2] Treatment includes bowel rest, orogastric tube, intravenous fluids, and intravenous antibiotics. [2] Surgery is required in those who have free air in the abdomen. [2] A number of other supportive measures may also be required. [2] Complications may include short-gut syndrome, intestinal strictures, or developmental delay. [2]

About 7% of those who are born prematurely develop NEC; however the odds of an infant developing this illness is directly related to the intensive care unit they are placed in. [4] [2] [11] [12] [13] Onset is typically in the first four weeks of life. [2] Among those affected, about 25% die. [1] The sexes are affected with equal frequency. [14] The condition was first described between 1888 and 1891. [14]

Signs and symptoms

The condition is typically seen in premature infants, and the timing of its onset is generally inversely proportional to the gestational age of the baby at birth (i.e., the earlier a baby is born, the later signs of NEC are typically seen). [15]

Initial symptoms include feeding intolerance and failure to thrive, increased gastric residuals, abdominal distension, and bloody stools. Symptoms may progress rapidly to abdominal discoloration with intestinal perforation and peritonitis and systemic hypotension requiring intensive medical support. [16]

Cause

The exact cause is unclear. [1] Several risk factors have been implicated: [17]

Maternal factors

Main risk factors

Other risk factors

Diagnosis

Radiograph of a baby with necrotizing enterocolitis Necrotizing enterocolitis 202.jpg
Radiograph of a baby with necrotizing enterocolitis

Diagnosis is usually suspected clinically, but often requires the aid of diagnostic imaging, most commonly radiography, which can show the intestines and may show areas with dead tissue or a bowel perforation. [18] Specific radiographic signs of NEC are associated with specific Bell's stages of the disease: [19]

Ultrasonography has proven to be useful, as it may detect signs and complications of NEC before they are evident on radiographs, specifically in cases that involve a paucity of bowel gas, a gasless abdomen, or a sentinel loop. [21] Diagnosis is ultimately made in 5–10% of very-low-birth-weight infants (<1,500g). [22]

Diagnosis of NEC is more challenging in premature infants, due to inexplicit symptoms and radiographic signs. The most preterm infant is at highest risk of developing NEC. [23]

Prevention

Prevention includes the use of breast milk and probiotics. [2] A 2012 policy by the American Academy of Pediatrics recommended feeding preterm infants human milk, finding "significant short- and long-term beneficial effects," including reducing the rate of NEC by a factor of one-half to three-quarters. [24]

Small amounts of oral feeds of human milk starting as soon as possible, while the infant is being primarily fed intravenously, primes the immature gut to mature and become ready to receive greater intake by mouth. [25] Human milk from a milk bank or donor can be used if mother's milk is unavailable. The gut mucosal cells do not get enough nourishment from arterial blood supply to stay healthy, especially in very premature infants, where the blood supply is limited due to immature development of the capillaries, so nutrients from the lumen of the gut are needed.[ citation needed ]

Towards understanding intervention with human milk, experts have noted cow's and human milk differ in their immunoglobular and glycan compositions. [26] [27] Due to their relative ease of production, human milk oligosaccharides (HMO) are a subject of particular interest in supplementation and intervention. [28]

A Cochrane review in 2020 (updated in 2023) found low- to moderate-quality evidence that supplementation of probiotics enterally "prevents severe NEC, as well as all-cause mortality in preterm infants" but cautioned that the evidence was not sufficient to inform policy and practice and that further high-quality trials are needed. [29]

Advancing enteral feed volumes at lower rates does not appear to reduce the risk of NEC or death in very preterm infants and seems to increase the risk of invasive infection. [30] Not beginning feeding an infant by mouth for more than 4 days does not appear to have protective benefits. [31]

Treatment

If a baby is diagnosed with NEC, treatment should begin immediately. [18] Treatment consists primarily of supportive care, including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third-space losses, support for blood pressure, parenteral nutrition, [32] and prompt antibiotic therapy.

Monitoring is clinical, although serial supine and left lateral decubitus abdominal X-rays should be performed every six hours. [33]

As an infant recovers from NEC, feeds are gradually introduced. "Trophic feeds" or low-volume feeds (<20 ml/kg/day) are usually initiated first. How and what to feed are determined by the extent of bowel involved, the need for surgical intervention, and the infant's clinical appearance. [34]

Where the disease is not halted through medical treatment alone, or when the bowel perforates, immediate emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure. Surgery may require a colostomy, which may be able to be reversed at a later time. Some children may develop short bowel syndrome if extensive portions of the bowel must be removed.[ citation needed ]

In the case of an infant whose bowel is left in discontinuity, the surgical creation of a mucous fistula or connection to the distal bowel may be helpful, as this allows for refeeding of ostomy output to the distal bowel. This refeeding process is believed to improve bowel adaptation and aid in advancement of feeds. [34]

Prognosis

Typical recovery from NEC if medical, nonsurgical treatment succeeds, includes 10–14 days or more without oral intake, and then demonstrated ability to resume feedings and gain weight. Recovery from NEC alone may be compromised by co-morbid conditions that frequently accompany prematurity. Long-term complications of medical NEC include bowel obstruction and anemia.[ citation needed ]

In the United States, NEC caused 355 deaths per 100,000 live births in 2013, down from 484 per 100,000 live births in 2009. Rates of death were almost three times higher for the black population than for the white population. [35]

When NEC is diagnosed and treated immediately, the prognosis for babies is generally very good. Most babies recover fully without any additional health problems. [18] Overall, about 70-80% of infants who develop NEC survive. [36] Medical management of NEC shows an increased chance of survival compared to surgical management. [36] Despite a significant mortality risk, long-term prognosis for infants undergoing NEC surgery is improving, with survival rates of 70–80%. However, "Surgical NEC" survivors are still at risk for possible long-term complications, such as narrowing of the intestines [18] or Short bowel syndrome and neurodevelopmental disability.

Society and advocacy

The NEC Society is a 501(c)(3), non-profit organization dedicated to building a world without necrotizing enterocolitis (NEC) through research, advocacy, and education. The NEC Society was launched in January 2014 by Jennifer Canvasser after her son, Micah, died from complications of NEC just before his first birthday. The NEC Society is a patient-led organization that collaborates with expert clinicians and researchers to better understand, prevent, and treat this devastating neonatal intestinal disease. Today, patient-families and experts from around the world work together to improve outcomes for the most vulnerable infants at risk of NEC. Their work and numerous initiatives combine the patient-family perspective with solutions based on the best available scientific evidence.

NEC Symposium

The NEC Society hosts an in-person, biennial Symposium where clinicians, scientists and patient-families come together to listen, learn and collaborate. It is held as an “All-In Meeting", where all stakeholders are fully integrated and empowered. Patient-families are central to the planning, preparation, and execution of the meeting. Each session is dedicated to a baby affected by NEC. Patient-families take part in each session as faculty and also present posters.

Related Research Articles

<span class="mw-page-title-main">Intrauterine growth restriction</span> Medical condition

Intrauterine growth restriction (IUGR), or fetal growth restriction, is the poor growth of a fetus while in the womb during pregnancy. IUGR is defined by clinical features of malnutrition and evidence of reduced growth regardless of an infant's birth weight percentile. The causes of IUGR are broad and may involve maternal, fetal, or placental complications.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

<span class="mw-page-title-main">Patent ductus arteriosus</span> Condition wherein the ductus arteriosus fails to close after birth

Patent ductus arteriosus (PDA) is a medical condition in which the ductus arteriosus fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs through the aorta, which has a higher blood pressure, to the pulmonary artery, which has a lower blood pressure. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased work of breathing and failure to gain weight at a normal rate. With time, an uncorrected PDA usually leads to pulmonary hypertension followed by right-sided heart failure.

<span class="mw-page-title-main">Kangaroo care</span> Technique of newborn care

Kangaroo mother care (KMC), which involves skin-to-skin contact (SSC), is an intervention to care for premature or low birth weight (LBW) infants. The technique and intervention is the recommended evidence-based care for LBW infants by the World Health Organization (WHO) since 2003.

<span class="mw-page-title-main">Gastroschisis</span> Defect resulting in visible intestines

Gastroschisis is a birth defect in which the baby's intestines extend outside of the abdomen through a hole next to the belly button. The size of the hole is variable, and other organs including the stomach and liver may also occur outside the baby's body. Complications may include feeding problems, prematurity, intestinal atresia, and intrauterine growth restriction.

<span class="mw-page-title-main">Short bowel syndrome</span> Medical condition

Short bowel syndrome is a rare malabsorption disorder caused by a lack of functional small intestine. The primary symptom is diarrhea, which can result in dehydration, malnutrition, and weight loss. Other symptoms may include bloating, heartburn, feeling tired, lactose intolerance, and foul-smelling stool. Complications can include anemia and kidney stones.

<span class="mw-page-title-main">Neonatal intensive care unit</span> Intensive care unit specializing in the care of ill or premature newborn infants

A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit (ICU) specializing in the care of ill or premature newborn infants. The NICU is divided into several areas, including a critical care area for babies who require close monitoring and intervention, an intermediate care area for infants who are stable but still require specialized care, and a step down unit where babies who are ready to leave the hospital can receive additional care before being discharged.

<span class="mw-page-title-main">Low birth weight</span> Birth weight of an infant of 2,499 g (5 lb 8.1 oz) or less

Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of 2,499 g or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal intensive care unit (NICU). They are also at increased risk for long-term health conditions which require follow-up over time.

<span class="mw-page-title-main">Birth weight</span> Weight of a human baby at birth

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Antenatal steroids, also known as antenatal corticosteroids, are medications administered to pregnant women expecting a preterm birth. When administered, these steroids accelerate the maturation of the fetus' lungs, which reduces the likelihood of infant respiratory distress syndrome and infant mortality. The effectiveness of this corticosteroid treatment on humans was first demonstrated in 1972 by Sir Graham Liggins and Ross Howie, during a randomized control trial using betamethasone.

<span class="mw-page-title-main">Bronchopulmonary dysplasia</span> Medical condition

Bronchopulmonary dysplasia is a chronic lung disease which affects premature infants. Premature (preterm) infants who require treatment with supplemental oxygen or require long-term oxygen are at a higher risk. The alveoli that are present tend to not be mature enough to function normally. It is also more common in infants with low birth weight (LBW) and those who receive prolonged mechanical ventilation to treat respiratory distress syndrome. It results in significant morbidity and mortality. The definition of bronchopulmonary dysplasia has continued to evolve primarily due to changes in the population, such as more survivors at earlier gestational ages, and improved neonatal management including surfactant, antenatal glucocorticoid therapy, and less aggressive mechanical ventilation.

<span class="mw-page-title-main">Chorioamnionitis</span> Medical condition

Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes, usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development Workshop expert panel recommended use of the term "triple I" to address the heterogeneity of this disorder. The term triple I refers to intrauterine infection or inflammation or both and is defined by strict diagnostic criteria, but this terminology has not been commonly adopted although the criteria are used.

Clostridial necrotizing enteritis (CNE) is a severe and potentially fatal type of food poisoning caused by a β-toxin of Clostridium perfringens, Type C. It occurs in some developing regions, particularly in New Guinea, where it is known as pig-bel. The disease was also documented in Germany following World War II, where it was called Darmbrand (literally "bowel fire," or bowel necrosis). The toxin is normally inactivated by certain proteolytic enzymes and by normal cooking, but when these protections are impeded by diverse factors, and high protein is consumed, the disease can emerge.

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<span class="mw-page-title-main">Neonatal infection</span> Human disease

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<span class="mw-page-title-main">Human milk immunity</span> Protection provided to immune system via human milk

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Breast milk-mediated drug delivery refers to the use of breast milk to transport a pharmaceutical compound, protein, or other treatment to achieve a desired effect. Delivery of these substances via milk provides an oral alternative for transport of a compound to the gut, specifically in infants. Breast milk-mediated drug delivery provides a way for pharmaceuticals and proteins to travel through the gastrointestinal system of an infant while minimizing the potential for irritation within gastrointestinal tissue.

References

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