Necrotizing Enterocolitis (NEC)

(pg. 365-366)

Definition Acute inflammatory disease of the bowel with increased incidence in preterm and other high-risk infants. It is most common in preterm infants Signs are similar to those of many other diseases, nurses must constantly be aware of the possibility of this disease. Etiology Uncertain Prematurity = MOST PROMINENT risk factor Appears to occur in infants whose GI tract has vascular compromise Possible etiology: Intestinal ischemia, Immature GI host defenses, Bacterial proliferation, Feeding substrate Pathophysiology Damage to mucosal cells lining the bowel wall Diminished blood supply to mucosal cells causes their death Unable to secrete protective, lubricating mucus Thin, unprotected bowel wall is attacked by proteolytic enzymes Gas-forming bacteria produce intestinal pneumatosis (presence of air in submucosal/subserosal surfaces of bowel) Onset: 4-10 days after initiation of feedings (may be evident w/in 4 hr or 30 days) NEC in full-term infants almost always occurs in first 10 days of life Late-onset NEC confined to preterm infants and coincides with the onset of feedings after they have passed the acute phase of an illness such as RDS Clinical Manifestations Closely resembles septicemia Infant may not look well **Prominent signs: Distended abdomen, Gastric residuals, Blood in stools Nonspecific signs: Lethargy, Poor feeding, Hypotension, Apnea, Vomiting (often bile stained), Decreased urinary output, & Hypothermia Complications Septicemia DIC Hypoglycemia Other metabolic derangements Diagnostic Evaluation Radiographic studies show a sausage-shaped dilation of intestine which progresses to marked distension & the characteristic intestinal pneumatosis soapsuds, or bubbly appearance of thickened bowel wall & ultralumina. Air may be present and indicates perforation Lab Findings: anemia, leukopenia, leukocytosis, metabolic acidosis, Lyte imbalance DIC or thrombocytopenia if severe

Therapeutic Management Prevention: May hold oral feedings for 24-48 hr from infants who suffered birth asphyxia; Breast milk preferred enteral nutrient Medical Mgmt: D/c of all oral feedings NGT abd decompression IV antibiotics Correction of extravascular volume depletion, Lyte and acid-base imbalances, & hypoxia Replace oral feedings w/parenteral fluids ( need for O2 and bowel circulation) Serial abd X-Ray (Q4-6H) in acute phase monitor possible progression/perforation Med mgmt is Successful w/early recognition and tx Progressive deterioration or perforation - Surgical resection and anastomosis Extensive involvement - Ileostomy, jejunostomy, or colostomy Intestinal transplant and bowel lengthening procedures (may save life of infant who previously faced high morbidity and mortality) Tissue-engineered small intestine currently being studied as lifesaving tx for SBS Sequelae in surviving infants SBS Colonic stricture w/obstruction Fat malabsorption Failure to thrive secondary to intestinal dysfunction Nursing Care Management Prompt recognition of early warning signs of NEC CONTROL INFECTION strict handwashing is the primary barrier to spread Persons with sxs of GI infection should NOT care for these/or and other infants! Assist with diagnostic procedures and implement therapeutic regimen VS monitored for changes that might indicate perforation, septicemia, CV shock AVOID rectal temperatures (this can increase chance of perforation if done) To avoid pressure on abd, infant is left undiapered & in supine or side position Nutirition and hydration = essential Antibiotics Oral feedings are usually reinstituted 7-10 days after dx and tx Sterile H2O and Lyte soln may be given initially, followed by human milk or elemental formula such as Pregestimil

NURSING ALERT Observe for indications of early development of NEC by checking abd frequently for distention (measuring abd grith, measuring residual GI contents before feedings, & listening for the presence of bowel sounds) & performing all routine assessments for high-risk neonates.
Hockenberry, M., & Wilson, D. (2011). Wong's nursing care of infants and children. (9th ed.). St Louis MO: Mosby.