Part 1. Current Controversies in the Understanding of Necrotizing Enterocolitis

Barbara Noerr, RNC, MSN, CRNP

Disclosures

Adv Neonatal Care. 2003;3(3) 

In This Article

Abstract and Introduction

Necrotizing enterocolitis (NEC) has widespread implications for neonates. While mostly affecting preterm neonates, full-term neonates, especially those with congenital heart disease, are also at risk. Although the exact pathogenesis of NEC remains elusive, three major factors, a pathogenic organism, enteral feedings, and bowel compromise, coalesce in at-risk neonates to produce bowel injury. Initiation of the inflammatory cascade likely serves as a common pathway for the disorder.

Clinical signs and symptoms range from mild feeding intolerance with abdominal distension to catastrophic disease with bowel perforation, peritonitis, and cardiovascular collapse. Vigilant assessment of at-risk neonates is crucial. When conservative medical management fails to halt injury, surgical intervention is often needed. Strategies to decrease the incidence and ultimately prevent NEC loom on the horizon, such as exclusive use of human breastmilk for enteral feedings and administration of probiotics.

Necrotizing enterocolitis (NEC) is an acquired condition of diffuse necrotic injury to the mucosal and submucosal layers of the bowel. It is the most serious gastrointestinal (GI) disorder that occurs during the neonatal period.[1,2,3] The entire GI tract, from the stomach to the anus, is susceptible. The distal small gut and proximal colon are involved most frequently.[1] The lesions may be diffuse and contiguous or patchy and more focal in nature. Systemic signs and symptoms accompany GI injury.

Neonatal NEC initially was described in case reports of GI perforations in 1825 and 1891. In 1888, 5 deaths after long-segment bowel necrosis and multiple perforations were reported.[3,4] Credit for naming the disorder was given to Schmid and Quaiser in 1953 and then Rossier in 1959.[3,4,5] It was not until the mid-1960s that an in-depth delineation of this disorder, including clinical and radiographic findings, was published by Berdon[6] and then Mizrahi[7] and their respective colleagues.

Despite numerous case reports, decades of clinical experience, and multiple research studies examining this condition, a complete understanding of NEC remains unclear. Part 1 of this series provides a comprehensive review of current discoveries and ongoing controversies surrounding this disorder. The definition, incidence, and staging are discussed. Risk factors and differences in the presentation of NEC in preterm and full-term infants are compared and contrasted. The interaction between mucosal injury, infection, enteral feedings, and prematurity is presented, along with important clinical considerations. Part 2 of the series will address the diagnosis of this disorder, outline key controversies in the medical and surgical management, and examine the prognosis and outcome of affected infants. The nursing care of infants with NEC will be presented along with a discussion of novel prevention strategies.

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