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Neonatal necrotizing enterocolitis — Clinical Guidelines

Overview

Neonatal necrotizing enterocolitis (NEC) is an inflammatory bowel disease primarily affecting preterm infants, characterized by necrosis of the intestinal mucosa, leading to significant morbidity and mortality. 8

Diagnosis

Key Diagnostic Criteria: Clinical signs include feeding intolerance, abdominal distension, bloody stools, and systemic inflammatory response. 8

Recommended Tests: Abdominal X-rays showing pneumatosis intestinalis and portal gas are crucial diagnostic tools. 8

Grading: NEC is typically classified using the Bell staging system (Stage I-III) to assess severity and guide management. 8

Management

First-Line Treatments: Supportive care including fluid resuscitation, broad-spectrum antibiotics, and bowel rest. 8

Adjunctive Treatments:

- Erythropoietin (EPO): Early EPO supplementation may reduce NEC incidence in preterm infants (dose and specifics not detailed). 1 - Damage Control Surgery (DCS): Used in severe cases to manage complications like acidosis, hypothermia, and coagulopathy, sacrificing definitive repair for immediate stabilization. 2 - Pain Management: Essential around surgical interventions; use of multimodal analgesia strategies as per unit protocols (specific agents not detailed). 3

Advanced Therapies:

- Mild Hypothermia: Feasible and safe in preterm infants with advanced NEC and multiple organ dysfunction syndrome (MODS) as a pilot study suggests. 7 - Considerations for Hyperviscosity: Monitor and manage hyperviscosity to prevent tissue hypoperfusion, especially in infants with NEC. 14

Special Populations

Preterm Infants: NEC predominantly affects very low birth weight (VLBW) infants, with higher mortality and morbidity rates. 5 11 12

Comorbidities: Infants with NEC often exhibit multisystem organ failure (MSOF) and capillary leak syndrome, correlating with disease severity and outcome. 12 13

Key Recommendations

Consider Early Erythropoietin Supplementation: For preterm infants to potentially reduce the incidence of NEC (Evidence: Moderate 1).

Implement Damage Control Surgery Strategically: In neonates with severe NEC to manage life-threatening complications effectively (Evidence: Expert opinion 2).

Prioritize Comprehensive Pain Management: Around surgical interventions for NEC to improve patient comfort and outcomes (Evidence: Weak 3).

Monitor for and Manage Multisystem Organ Failure: Closely observe and intervene for respiratory, renal, cardiovascular, and hepatic failures in NEC patients (Evidence: Moderate 12 13).

Evaluate Feasibility of Mild Hypothermia: In preterm infants with advanced NEC and MODS as a potential adjunctive therapy (Evidence: Weak 7).

References

1 Ananthan A, Balasubramanian H, Mohan D, Rao S, Patole S. Early erythropoietin for preventing necrotizing enterocolitis in preterm neonates - an updated meta-analysis. European journal of pediatrics 2022. link 2 Arul GS, Singh M, Ali AM, Gee OJ. Damage control surgery in neonates: Lessons learned from the battlefield. Journal of pediatric surgery 2019. link 3 Meesters NJ, van Dijk M, Knibbe CA, Keyzer-Dekker CM, Tibboel D, Simons SH. Infants Operated on for Necrotizing Enterocolitis: Towards Evidence-Based Pain Guidelines. Neonatology 2016. link 4 McElroy SJ, Underwood MA, Sherman MP. Paneth cells and necrotizing enterocolitis: a novel hypothesis for disease pathogenesis. Neonatology 2013. link 5 Thyoka M, de Coppi P, Eaton S, Khoo K, Hall NJ, Curry J et al.. Advanced necrotizing enterocolitis part 1: mortality. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2012. link 6 Zani A, Ghionzoli M, Lauriti G, Cananzi M, Smith VV, Pierro A et al.. Does intestinal permeability lead to organ failure in experimental necrotizing enterocolitis?. Pediatric surgery international 2010. link 7 Hall NJ, Eaton S, Peters MJ, Hiorns MP, Alexander N, Azzopardi DV et al.. Mild controlled hypothermia in preterm neonates with advanced necrotizing enterocolitis. Pediatrics 2010. link 8 Schnabl KL, Van Aerde JE, Thomson AB, Clandinin MT. Necrotizing enterocolitis: a multifactorial disease with no cure. World journal of gastroenterology 2008. link 9 Hall NJ, Ali J, Pierro A, Eaton S. Total glutathione is not decreased in infants with necrotizing enterocolitis. Journal of pediatric surgery 2005. link 10 Sharma R, Garrison RD, Tepas JJ, Mollitt DL, Pieper P, Hudak ML et al.. Rotavirus-associated necrotizing enterocolitis: an insight into a potentially preventable disease?. Journal of pediatric surgery 2004. link 11 Sonntag J, Grimmer I, Scholz T, Metze B, Wit J, Obladen M. Growth and neurodevelopmental outcome of very low birthweight infants with necrotizing enterocolitis. Acta paediatrica (Oslo, Norway : 1992) 2000. link 12 Sonntag J, Wagner MH, Waldschmidt J, Wit J, Obladen M. Multisystem organ failure and capillary leak syndrome in severe necrotizing enterocolitis of very low birth weight infants. Journal of pediatric surgery 1998. link90092-6) 13 Morecroft JA, Spitz L, Hamilton PA, Holmes SJ. Necrotizing enterocolitis--multisystem organ failure of the newborn?. Acta paediatrica (Oslo, Norway : 1992). Supplement 1994. link 14 Leake RD, Thanopoulos B, Nieberg R. Hyperviscosity syndrome associated with necrotizing enterocolitis. American journal of diseases of children (1960) 1975. link

Neonatal necrotizing enterocolitis