Necrotizing Enterocolitis

1. Necrotizing Enterocolitis By: Brandis Miller Sodexo Dietetic Intern

2. Introduction • Professional Research Presentation • Why Necrotizing Enterocolitis (NEC)? • Why is this research important?

3. Objectives • Learners will be able to define NEC • Learners will be able to identify symptoms of NEC • Learners will be able to list recommended treatment options for NEC

4. Icebreaker – Baby Name Game Harper Seven Seraphina Rose Satchel Seamus Bingham Hawn

5. Defining NEC • “An acute inflammatory condition of the bowel that affects 6-7% of all premature infants with birth weights of <1,250 g and is also one of the leading causes of mortality among these infants.” • Pathophysiology is thought to involve immaturity of the immune, circulatory, and digestive systems; hypoxic-ischemic injury, enteral feeding, and pathologic bacterial colonization 5, 6

6. Incidence and Risk Factors • Most often develops while the infant is still in the hospital • Those with higher risk include: • Premature infants • Infants who are fed concentrated formulas • Infants in a nursery where an outbreak has occurred • Infants who have received blood exchange transfusions 2

7. Symptoms • May come on slowly or suddenly • Abdominal distention • Blood in the stool • Diarrhea • Feeding intolerance • Lethargy • Temperature instability • Vomiting 2

8. Signs & Tests • Abdominal x-ray • Stool for occult blood test (guaiac) • Elevated white blood cell count in a CBC • Thromocytopenia • Lactic Acidosis 2

9. Treatment • Hold feedings • Relieve gas from the bowel • IV fluids or TPN • Antibiotic therapy • Monitor infant’s condition • Abdominal x-rays • Blood tests • Blood gases • Surgery may be warranted in some cases 2, 5, 6

10. Prognosis • Death rate approaching 25% • Early, aggressive treatment helps improve outcome • Complications • Intestinal perforation • Intestinal stricture • Peritonitis • Sepsis 2, 6

11. Lowering the Risk • Evidence supports the beneficial effects of human milk (HM) to reduce the risk for NEC in premature infants 1,3,4,5,6

12. 2007 Study Sisk, P., Lovelady, C., Dillard, R., Gruber, K., & O'Shea, T. (2007). Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. Journal of Perinatology, 428-433. • Objective: To determine if high proportions of (50% or greater) HM enteral feeding within the first 14 days of life are protective against NEC • 202 infants were studied with confirmed NEC in 5/46 infants receiving <50% human milk and 5/156 infants receiving >50% human milk • For every 25% increase in HM proportion in the first 14 days, the odds of NEC decreased by 38% • Limits: Non-randomized design, potential for selection bias, results possibly affected by feeding practices 6

13. 2009 Study Meinzen-Der, J., Poindexter, L., Wrage, L., Morrow, A., & Donovan, E. (2009). Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. Journal of Perinatology, 57-62. • Objective: To determine the association between HM intake and risk of NEC or death among infants 401 to 1000 g birth weight • Among 1,272 study infants, 13.6% died or developed NEC after 14 days • Data suggests a dose-related association of HM feeding with a reduction of risk of NEC or death after the first 2 weeks of life among extremely low birth weight infants • Limits: Variability in defining HM intake, unable to adjust for parent preferences or differences in individual clinician practice style 5

14. 2012 Study Ganapathy, V., Hay, J. W., & Kim, J. H. (2011). Costs of Necrotizing Enterocolitis and Cost-Effectiveness of Exclusively Human Milk-Based Products in Feeding Extremely Premature Infants. Breastfeeding Medicine, 29-37. • Objective: To evaluate the cost-effectiveness of a 100% human milk-based diet composed of mother’s milk fortified with a donor human milk-based fortifier vs mother’s milk fortified with bovine milk-based fortifier to initiate enteral nutrition among extremely premature (EP) infants in the NICU • A net expected costs calculator was developed to compare total NICU costs based on previously observed risks of overall NEC • 100% human milk-based diet may result in potential net savings on medical care resources by preventing NEC • Limits: Relatively small number of NICU units participated, Prolacta HMF not yet widely used at the time of the study 3

15. Study Conclusions • Enteral feeding with HM early in life significantly decreases infant’s risk of developing NEC • Protective effects of HM have been observed even with partial feeding of HM, even if not exclusively fed HM • Recommendation to encourage HM feeding to prevent NEC can be supported by evidence presented in these and other studies 3,5,6

16. Topic Evaluation • Early, aggressive nutrition is key • If the gut works, use it! • Initiate trophic feeds if necessary • HM is the “gold standard” • Encourage DBM when/if indicated • NEC prevention education should be given to moms of at risk infants who are reluctant to use DBM or provide their own HM

17. Here at Children’s St. Paul • Early, aggressive nutrition • Donor breast milk (DBM) available to all infants born <1500 g and <34 weeks • Goal is to avoid formula in these infants • DBM continued until the infant reaches 34 weeks and 1500 g

18. Review • NEC: An acute inflammatory condition of the bowel that affects 6-7% of all premature infants with birth weights of <1,250 g and is also one of the leading causes of mortality among these infants • Symptoms can come on slowly or suddenly and include: abdominal distention, blood in the stool, diarrhea, feeding intolerance, lethargy, temperature instability, and vomiting Abdominal distention • Treatment: hold feedings, relieve gas from the bowel, IV fluids or TPN, antibiotic therapy, monitor infant’s condition, surgery may be warranted • Evidence supports the beneficial effects of human milk (HM) to reduce the risk for NEC in premature infants

19. Questions

20. Resources • Cilieborg, M. S., Boye, M., & Sangild, P. T. (2011). Bacterial colonization and gut development in preterm neonates. Early Human Development , 41-49. • Eisner, T. M., & Zieve, M. M. (2011, May). PubMed Health. Retrieved from A.D.A.M. Medical Encyclopedia: http://ncbi.nlm.nih.gov/pubmedhealth/PMH0002133/?report=printable • Ganapathy, V., Hay, J. W., & Kim, J. H. (2011). Costs of Necrotizing Enterocolitis and Cost-Effectiveness of Exclusively Human Milk-Based Products in Feeding Extremely Premature Infants. Breastfeeding Medicine , 29-37. • Juretschke, L. J.-N.-B. (2010, December). Using and fortifying human milk for very preterm babies int he neonatal intensive care unit. NICU Currents , pp. 1-8. • Meinzen-Der, J., Poindexter, L., Wrage, L., Morrow, A., & Donovan, E. (2009). Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. Journal of Perinatology , 57-62. • Sisk, P., Lovelady, C., Dillard, R., Gruber, K., & O'Shea, T. (2007). Early human milk feeding is associated with a lower risk of necrotizing enterocolities in very low birth weight infants. Journal of Perinatology , 428-433.