Necrotizing Enterocolitis By: Brandis Miller Sodexo Dietetic Intern

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions

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.