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Necrotizing enterocolitis

Battling an enigma

Gephart, Sheila PhD, RN; Lanning Lowther, Lisa C. DO, PA-C

Journal of the American Academy of PAs: August 2017 - Volume 30 - Issue 8 - p 8–9
doi: 10.1097/01.JAA.0000521145.55572.ae
Commentary
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Sheila Gephart is an associate professor in the College of Nursing at the University of Arizona in Tucson. Lisa C. Lanning Lowther is a resident physician in the McLeod Family Medicine Residency Program in Florence, S.C. Dr. Gephart discloses that she received training support from the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation. The views expressed here do not necessarily represent the views of either organization. The authors, who are sisters, have disclosed no other potential conflicts of interest, financial or otherwise.

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On page 16 of this issue, Alysia Agnoni, MS, PA-C, and Christine Lazaros Amendola, MS, PA-C, inform practitioners about necrotizing enterocolitis (NEC) and what they need to do to recognize, diagnose, and treat it. As survival of children born at earlier gestations becomes possible, NEC is one of the most concerning complications of premature birth because it leads to long-term complications and can kill. Compared with other morbidities of early life, NEC is one complication of prematurity with little improvement over the last decade.1 Countries with high use of probiotics, standardized feeding protocols, and human milk feeding show rates lower than in the United States.2,3 Clinicians who do not directly care for neonates in intensive care settings may wonder about the relevance of NEC to their practice. In fact, primary care providers also may be undereducated about this devastating problem, as a review of the recent primary care literature barely mentions NEC.

The good news is that actions taken to prevent NEC can systematically support the health of both the infant and the mother in the long term, especially actions to prevent premature birth and support breastfeeding. Providing infants with early and exclusive access to human milk has been shown to reduce NEC.3,4 Colaizy and colleagues estimate that suboptimal feeding of US infants with formula (that is, less than 90% of infants fed less than 98% of their diet with human milk) is associated with 928 cases of NEC and 121 deaths a year.5 Changing practice to optimize human milk feeding could save $27 million in direct costs of care and up to $1.5 billion related to prematurely lost life every single year.5

Although the exact pathogenesis of NEC is unclear, we know it is multifactorial and that some NICU practices are eliminating the disease from their NICUs.6 This concept of “getting to zero NEC” cannot be done without engaging the entire family and care team. Simple actions backed by evidence that every clinician can do today to prevent NEC include:

  • Beginning in the prenatal setting, promote human milk feeding to all patients regardless of ethnicity, age, or situation. Instead of asking, “Do you plan to breast- or bottle-feed?” ask “Can I tell you about the benefits of human milk feeding for your baby?” or “What support can we offer so that you can give your baby human milk?” For mothers who do not wish to breastfeed, ask them to pump for at least a month when the infant is born early. Mothers who are unable to breastfeed also can feed their infants donor human milk.
  • If premature birth is imminent, transfer the patient to an appropriate setting with full NICU care before the birth. Giving the mother antenatal steroids has been shown to prevent NEC and mature the infant's lungs.7 Regionalized neonatal care has been shown to improve survival for preterm infants, with high-volume centers showing strong outcomes, making early transfer (before the baby is born or soon after) critical.
  • Advocate for an exclusive human milk diet that is fed according to a unit-adopted standardized feeding protocol.8 A unit-adopted standardized approach to feeding the preterm infant has been shown to reduce NEC. Beyond the NICU, hospital systems that emphasize the Baby-Friendly Initiative (https://www.babyfriendlyusa.org) also promote breastfeeding to all families, possibly reducing downstream nutritional complications for otherwise healthy term infants. Informing parents about the risk of formula feeding in the preterm infant and the vital role they play to provide human milk engages them as partners in prevention (www.necsociety.org).
  • Evidence for probiotics to prevent NEC is mounting. However, controversy persists, and adoption is slow while providers wait for a consistent FDA-supported formulation and US-based studies.9 Sharing with parents the risks and benefits of probiotics for their preterm infant is a good opportunity to engage in shared decision making, especially in light of the very strong evidence supporting probiotics' effectiveness in preventing NEC.
  • If an infant develops NEC, ensure quick access to surgical consultation. If pediatric surgical services are not available, transport the infant to a higher level of care without delay.
  • The recovery period for NEC can be long and the number of experts involved in the care of these critically ill infants is significant. Continue to include the family in care conferences and daily rounds. Know that once the infant is discharged from the hospital, follow-up care will be extensive. Connecting the parents to support communities such as www.preemieparentalliance.org will reduce their isolation and support their ability to care for their infant.
  • Long-term effects of NEC can be significant. Survivors can develop intestinal strictures, bowel obstructions, extensive food allergies, and require long-term enteral or parenterally delivered nutrition. Those treated surgically or with the most severe NEC also can have neurodevelopmental delays. These children will need early intervention services and pediatric specialty care. Some parents report that their children require hospitalization several times a year because of bowel obstruction and functional bowel complications from NEC.10

NEC is like many conditions for which evidence exists but the consistent implementation of that evidence varies, and NICUs ultimately show different NEC rates. Agnoni and Amendola echo others in the neonatal community when they write that, “Though reports of [NEC] span back at least five decades, its pathogenesis remains an enigma, and the incidence in many NICUs remains the same and has even increased in some.” Yet, perhaps the mystery lies in deciphering how some NICU practices are eliminating or drastically reducing NEC. Perhaps the first step in breaking through scientific inertia lies in bridging the gulf between what we know and what we do.

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