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Key Features

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Essentials of Diagnosis
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  • Feeding intolerance with gastric residuals or vomiting

  • Bloody stools

  • Abdominal distention and tenderness

  • Pneumatosis intestinalis on abdominal radiograph

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General Considerations
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  • Most common in preterm infants, with an incidence of 10% in infants less than 1500 g

  • In full-term infants, it occurs in association with polycythemia, congenital heart disease, and birth asphyxia

  • Pathogenesis is multifactorial and includes

    • Ischemia

    • Immaturity

    • Microbial dysbiosis (proliferation of pathogenic bacteria with less colonization with beneficial or commensal bacteria)

    • Genetics

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Clinical Findings

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  • Abdominal distention, tenderness

  • Vomiting

  • Increased gastric residuals

  • Heme-positive stools

  • Temperature instability

  • Increased apnea and bradycardia

  • Decreased urinary output

  • Poor perfusion

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Diagnosis

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  • Increased white blood cell count with an increased band count or, as the disease progresses, absolute neutropenia may be present

  • Thrombocytopenia often occurs along with stress-induced hyperglycemia and metabolic acidosis

  • Plain abdominal radiograph showing presence of pneumatosis intestinalis (air in the bowel wall) or biliary tract air confirms diagnosis

  • Milder cases may exhibit only distention of bowel loops with bowel wall edema

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Treatment

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Medical
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  • Initial measures

    • Infant should take nothing by mouth

    • Nasogastric decompression of the gut

    • Maintenance of oxygenation

    • Mechanical ventilation if necessary

    • Intravenous fluids: enough to replace third-space gastrointestinal losses and restore good urinary output

  • Other measures include

    • Broad-spectrum antibiotics (usually ampicillin, a third-generation cephalosporin or an aminoglycoside, and possibly additional anaerobic coverage)

    • Close monitoring of vital signs

    • Serial physical examinations and laboratory studies (blood gases, white blood cell count, platelet count, and radiographs)

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Surgery
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  • Needed in < 25% of cases

  • Indications

    • Evidence of perforation (free air present on a left lateral decubitus or cross-table lateral film)

    • Fixed dilated loop of bowel on serial radiographs

    • Abdominal wall cellulitis

    • Deterioration despite maximal medical support

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Outcome

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Follow-Up
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  • Total parenteral nutrition is provided until the disease is resolved (normal abdominal examination and resolution of pneumatosis), usually after 7–10 days

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Prevention
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  • No proven strategies but use of trophic feedings, breast milk, and cautious advancement of feeds, as well as probiotic agents, may provide some protection

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Prognosis
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  • Death occurs in 10% of cases

  • Long-term prognosis is determined by the amount of intestine lost. Infants with short bowel require long-term support with intravenous nutrition

  • Late strictures—about 3–6 weeks after initial diagnosis—occur in 8% of patients whether treated medically or surgically, and generally require operative management

  • Infants with surgically managed NEC have an increased risk of poor neurodevelopmental outcome

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References

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Alfaleh  K  et al: Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev 2011 Mar 16;3:CD005496
[PubMed: 21412889] .
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Neu  J, Walker  A: Necrotizing enterocolitis. N Engl J ...

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