Necrotising Enterocolitis (NEC)

Necrotising Enterocolitis (NEC) - What it is

Necrotising Enterocolitis (NEC) is a serious condition occurring mainly in premature babies where the intestine becomes swollen and inflamed may be irreversibly damaged. NEC can affect just a small part or rarely the whole intestine. It can lead to perforation in the intestine resulting in contents of the intestine leaking into the abdomen. Sometimes, the inflammation maybe fulminating and cause extensive damage to the intestines which is inoperable and lead to a baby’s demise.

Necrotising Enterocolitis (NEC) - Symptoms

Symptoms of NEC include a distended and discoloured abdomen, vomiting and blood in the stools. Babies with NEC may also show general signs of being unwell such as irregular breathing, low blood pressure and a fast heartbeat, poor feeding and lethargy.

Necrotising Enterocolitis (NEC) - How to prevent?

The exact causes of NEC are still unclear, and hence prevention is often difficult. It is likely to be multifactorial (prematurity, intolerance of milk feeds, infection, poor foetal growth, rapid escalation of feeding in a baby who is unable to tolerate this). Studies have shown that babies who received only breast milk (rather than formula) are less likely to develop NEC.

Necrotising Enterocolitis (NEC) - Causes and Risk Factors

Babies who are born premature or sick generally have a more fragile gastrointestinal tract It is not clear exactly what causes NEC, but it is thought that the intestinal tissues are damaged by various factors including too little oxygen or blood flow, resulting in inflammation.

NEC usually affects premature babies, particularly those with low birth weight and those who are born unwell with other medical problems. Rarely, NEC can also affect babies born at term following a brief intercurrent illness. It mainly occurs in babies receiving some amount of milk compared to a baby who has never been fed.

It can also occur in babies who have multisystem illness, infection, PDA or use of NSAIDs for treatment of a PDA.

Sometimes other illnesses (e.g. infection, feed intolerance) may mimic clinical and radiological features of NEC.

Necrotising Enterocolitis (NEC) - Diagnosis

NEC is diagnosed by examining the baby for signs listed above. Apart from those signs, an X-ray may show a bubbly appearance in the intestine and signs of air or gas in the liver. Air may also be found outside the intestines in the abdomen if there is a hole in the intestine. The gold standard in diagnosis rests on visualising the intestines at surgery and obtaining a pathological sample of a piece of bowel that is resected. However, not every baby with NEC undergoes surgery so diagnosis in this situation is based on history, clinical and radiological signs and working in close collaboration with a Paediatric Surgeon.

Necrotising Enterocolitis (NEC) - Treatments

Treatment of NEC include the following:

Stopping feeds
A small tube called a nasogastric (NG) tube inserted from the nose into the stomach to keep the stomach empty
Nutrition and fluid via drip
Antibiotics for infection
Machine assisted breathing if the breathing is affected through a ventilator
Supportive care as required with attention to blood pressure, pain relief etc

However, if the baby develops a perforation or does not respond to the treatment above and is increasingly unwell with worsening parameters and x-rays, he/she will require surgery to remove the inflamed intestine. This decision will be taken in consultation with the Paediatric Surgeon involved.

Necrotising Enterocolitis (NEC) - Preparing for surgery

Before the surgery, the surgeon will explain about the operation in more detail, discuss any concerns that Parents may have and ask to sign a consent form giving permission for the baby to have the operation. The operation will be done under general anaesthesia and an anaesthetist will explain about the anaesthetic process.

All attempts will be made to ensure that the baby is ready for surgery and supportive measures in preparation for surgery and after surgical care planned and administered as necessary.

Necrotising Enterocolitis (NEC) - Post-surgery care

The baby will return to the neonatal intensive care unit to recover after the surgery. Immediately after surgery, most babies will most likely need help with breathing and so will be connected to a ventilator machine. They will also be given pain relief medication. While the intestine recovers, they will continue to receive nutrition through drip until they are ready for milk feeds.

If the portion of the intestine removed at surgery is significant and the bowel does not look very healthy, the surgeon might fashion an opening in the baby’s belly and sew the intestine to this ( Stoma). This allows stool to come out from intestines to a bag place outside. Several months after the initial surgery and once adequate growth and nutrition is achieved, the surgeon will then close the stoma and join the bowels together. A more detailed explanation regarding the operation and these possibilities will be explained in more detail to Parents by the Surgeon and the Neonatal team.

Mothers will be encouraged to continue to express breastmilk as breastmilk is preferred when the baby is ready for feeding after surgery. Occasionally, a special type of pre-digested formula may have to be given if the baby is showing signs of not absorbing breast milk.

Overview

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Article contributed by Neonatal ＆ Developmental Medicine, Singapore General Hospital

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