Diagnosis and Management of Necrotizing Enterocolitis: An International Survey of Neonatologists and Pediatric Surgeons

Abstract

Background: Necrotizing enterocolitis (NEC) is a serious complication of prematurity. Currently, there is limited evidence to guide investigation and treatment strategies. Objectives: To evaluate the parameters used to diagnose or exclude NEC, and to identify differences between neonatologists and pediatric surgeons. Methods: A scenario-based survey was sent to neonatologists and pediatric surgeons. Results: 173 physicians from 26 countries completed the survey (55% neonatologists and 45% pediatric surgeons). Bloody stools, abdominal tenderness, low platelet counts, and increased lactate levels increased the likelihood of NEC for 82, 72, 56, and 45% of respondents, respectively. Intestinal pneumatosis, portal venous gas, and pneumoperitoneum on X-ray increased the likelihood of NEC for 99, 98, and 92% of respondents, respectively. Clinical examination and laboratory tests were insufficient to exclude NEC, but normal intestinal movements and normal gut wall thickness on ultrasonography decreased the likelihood of NEC for 38 and 33% of respondents, respectively. Neonatologists more frequently relied on increased gastric residuals and abdominal distension to diagnose NEC (p = 0.04 and p = 0.03, respectively), whereas pediatric surgeons more frequently reported that absence of bloody stools helped to exclude NEC (p = 0.04). In a deteriorating patient with suspected NEC, 39% of respondents would broaden the antibiotic spectrum, and 42% would recommend a laparotomy. Conclusion: Our results indicate a wide variation in the management of NEC, with significant differences between neonatologists and pediatric surgeons. A better appreciation of the relative significance and weighting that should be applied to the clinical features and investigations should reduce the variation in interpretation that appears to exist.

Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection

“…Patients' nil per os (NPO) status is largely driven by clinical assessment. Decreased apneic and bradycardic events in conjunction with laboratory values including blood gas, white count, and thrombocytopenia, as well as abdominal imaging without the appearance of portal venous gas or pneumatosis intestinalis are indications of improving clinical status [33]. Despite apparent improvement in clinical status, clinicians may hesitate to restart feeds after an NPO period, as objective evidence reflecting the optimal time to begin feeding is lacking.…”

Sepsis and Oxidative Stress in the Newborn: From Pathogenesis to Novel Therapeutic Targets

“…As antibiotics are one of the milestones of medical treatment of NEC but inappropriate antibiotic courses are related to adverse outcomes, the optimal antibiotic regimen for patients with NEC is of crucial importance in clinical settings [ 84 , 85 ]. Two recent surveys reported high variability among different centers and within single centers in antibiotic treatments for NEC in terms of type and number of antibiotics and duration of treatment [ 84 , 85 ].…”

Toll-Like Receptor–Mediated Intestinal Inflammatory Imbalance in the Pathogenesis of Necrotizing Enterocolitis

“… 6 In those infants who survive the initial onset of disease, long-term complications often develop, including severe inflammatory lung disease, 7 which is more severe than the lung disease that develops in premature infants in the absence of NEC, 8 , 9 neurologic dysfunction, 6 , 10 and the presence of short-bowel syndrome, 11 which is a devastating result of extensive intestinal resection. There is no specific treatment for NEC beyond broad-spectrum antibiotics and intestinal resection, 12 and current efforts therefore have focused on preventive strategies, 13 , 14 which of course offer little solace to those who unfortunately develop the disease. On a positive note, work from a variety of investigators has begun to shed light on some of the key signaling pathways that lead to disease development, and that will form the basis of the current review.…”