NECROTIZING ENTEROCOLITIS FOLLOW UP

Necrotizing Enterocolitis FOLLOW-UP
Necrotizing Enterocolitis Further Inpatient Care:
• Prolonged parenteral nutrition is essential to optimize the baby's nutrition while the gastrointestinal tract is allowed enough time for recovery and return to normal functioning. Central venous access is essential to facilitate parenteral delivery of adequate calories and nutrients to the recovering premature baby to minimize catabolism and promote growth.

• Prolonged central venous access may be associated with an increased incidence of nosocomial infection, predominately with skin flora such as coagulase-negative Staphylococcus species. A high degree of clinical suspicion must be maintained to detect the subtle signs of such infection as early as possible.

• Parenteral administration of lipid formulations via central venous catheters is also associated with an increased incidence of catheter-related sepsis.
o Lipids coat the catheter's interior, allowing ingress of skin flora through the catheter lumen. A high degree of clinical suspicion is required for early detection of such an infection.
o If line infection is suspected, obtain a blood culture through the central line. Antibiotics effective against skin flora (eg, vancomycin) should be administered through the line. Obtain another central line blood culture if the results of the first culture are positive. Persistently positive line cultures require removing the central line.

• Prolonged parenteral nutrition may be associated with cholestasis and direct hyperbilirubinemia. This condition resolves gradually following initiation of enteral feeds.

• Prolonged broad-spectrum antibacterial therapy increases the premature infant's risk for fungal sepsis. o Almost all premature infants demonstrate fungal colonization of the intestinal tract. Antibacterial therapy inhibits normal gut flora and allows fungal overgrowth caused by the absence of normal bacterial inhibition. Although prophylactic antifungal therapy reduces the incidence of fungal colonization in premature infants, it does not reduce the incidence of fungal sepsis. Therefore, it is not a recommended standard practice in the management of the preterm neonates
o As with other systemic infections in this patient population, clinical signs of fungal sepsis can be subtle and nonspecific. Delay in detection and treatment of fungal sepsis can allow the formation of fungal balls intraocularly, in the kidney, and/or in the heart. This complication carries a high mortality rate and morbidity including blindness, obstructive renal failure, and endocarditis. A high index of suspicion for fungal infection must be maintained when a baby on broad-spectrum antibacterials develops signs of systemic infec

Necrotizing Enterocolitis Further Outpatient Care:
• If a baby goes home with a colostomy, parents need thorough instruction regarding the baby's care. Having the parent(s) room with the baby at the hospital for several days prior to discharge is advisable so that they can learn and demonstrate adequate caregiving skills.

• Babies who have undergone intestinal resection may experience short-gut syndrome. These babies require vigilant nutritional regimens to maintain adequate calories and vitamins for optimum growth and healing.

Necrotizing Enterocolitis Transfer: In the acute phase, patients with progressive NEC require pediatric surgical consultation. During refeeding, patients with or without previous surgical history may demonstrate signs of obstruction requiring surgical evaluation and/or intervention. Transfer the patient to a facility offering pediatric surgical expertise, if it is not available at the current location.

Necrotizing Enterocolitis Deterrence/Prevention:
• Breastfed babies have a lower incidence of NEC than formula-fed babies (Lucas, 1990; Eyal, 1982).

• Much anecdotal evidence exists about the role of feeding regimens in the etiology of NEC. Clinical research does not demonstrate definitive evidence for either causation or prevention. Although conventional wisdom recommends slow initiation and advancement of enteral feeds for premature infants, random trials do not show an increased incidence for babies in whom feeds have been started early in life versus after 2 weeks' chronologic age (Berseth, 1992; Meetze, 1992). In 1992, McKeown et al reported that rapid increase in feeding volume (>20 mL/kg/d) was associated with higher risk of NEC. However, in 1999, Rayyis et al showed no difference in NEC Bell stage greater than or equal to II in patients advanced at 15 mL/kg/d compared with those advanced at 35 mL/kg/d. Systematic review published by the Cochrane Collaboration in 1999 reported no effect on NEC of rapid feeding advancement for low–birth weight infants.

• Because early presentation of NEC can be subtle, high clinical suspicion is important when evaluating any infant with signs of feeding intolerance or other abdominal pathology. In general, continuing to feed a baby with developing NEC worsens the disease.

Necrotizing Enterocolitis Complications:
• Approximately 75% of all patients survive. Of those patients who survive, 50% develop a long-term complication. The 2 most common complications are intestinal stricture and short-gut syndrome.

• Intestinal strictures
o This complication can develop in infants with or without a preceding perforation.
o Incidence is 25-33%.
o Although the most likely location for acute disease is the terminal ileum, strictures most commonly involve the left side of the colon.
o Symptoms of feeding intolerance and bowel obstruction typically occur 2-3 weeks after recovery from the initial event.
o The presence and location of the obstruction is diagnosed using barium enema; surgical resection of the affected area is required. Many surgeons routinely perform barium enemas in their patients before bowel reanastomosis so that all necessary surgical intervention can be performed at one time.

• Short-gut syndrome
o This is a malabsorption syndrome resulting from removal of excessive or critical portions of small bowel necessary for absorption essential nutrients from intestinal lumen.
o Symptoms are most profound in babies who either have lost most of their small bowel or have lost a smaller portion that includes the ileocecal valve.
o Loss of small bowel can result in malabsorption of nutrients as well as fluids and electrolytes.
o The neonatal gut will grow and adapt over time, but long-term studies suggest that this growth may take as long as 2 years to occur. During that time, maintenance of an anabolic and complete nutritional state is essential for the growth and development of the baby. This is achieved by parenteral provision of adequate vitamins, minerals, and calories; appropriate management of gastric acid hypersecretion; and monitoring for bacterial overgrowth. The addition of appropriate enteral feedings during this time is important for gut nourishment and remodeling.