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,
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,
Objective: To determine the association between HM intake and risk of NEC or death among infants 401 to 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,
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 ,
Eisner, T. M., & Zieve, M. M. (2011, May). PubMed Health. Retrieved from A.D.A.M. Medical Encyclopedia:
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 ,
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 ,
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 ,