NeoNotes Journal Club
Andrew B. Kairalla MD, Editor
Reviewed by: Mindy Morris RN

11-024 | Additional Comments | Previous Article | Next Article | Search | List of Articles | Submit Comments | Index | FSN Home Page | Subscribe Now

Christensen RD, Wiedmeier SE, Baer VL Henry E, Gerday E, Lambert DK, Burnett J & Besner GE.  Antecedents of Bell stage III necrotizing enterocolitis.  Journal of Perinatology Volume 3 number 1 January 2010, 54-57.  PubMed

OBJECTIVES: New biopharmaceuticals hold promise for preventing or treating necrotizing enterocolitis. However, it is unclear whether any such biopharmaceutical that requires enteral administration could be administered using an 'early-treatment' paradigm. This study was undertaken to assess this issue based on data from every case of Bell stage III NEC cared for during the past 7 years at Intermountain Healthcare.

STUDY DESIGN: Patients with Bell stage III NEC were identified from electronic medical record repositories and the diagnosis was validated using operative reports. Electronic and paper records of each patient were then used to identify potential clinical and laboratory antecedents occurring within the 48 h period preceding the diagnosis of NEC.

RESULTS: One hundred eighteen patients had Stage III NEC. The earliest recognized antecedents were nonspecific for NEC (apnea/bradycardia, skin mottling and irritability). These were recorded at 2.8+/-2.1, 4.5+/-3.1 and 5.4+/-3.7 (mean+/-s.d.) hours, respectively, before NEC was diagnosed. The most commonly identified gastrointestinal antecedents were blood in the stools, increased abdominal girth and elevated pre-feeding gastric residuals or emesis. These were identified 2.0+/-1.9, 2.8+/-3.1 and 4.9+/-4.0 h before NEC was recognized. Thirty-eight percent had a blood transfusion (18+/-12 h) preceding the NEC. Tachycardia, tachypnea, hypotension and diarrhea were rarely identified as antecedents and no consistent laboratory antecedents were discovered.

CONCLUSIONS We judge that an 'early treatment of NEC' paradigm testing any pharmacological agent that must be administered enterally is not feasible. The first recognized antecedents of Bell stage III NEC are nonspecific for gastrointestinal pathology and insufficient time exists for dosing between the first gastrointestinal signs and placement of the gastric decompression tube

Comments:  This is a historic cohort study essentially designed to identify timing and consistency of symptoms of NEC noted before actual diagnosis.  Based on the findings of the authors, most of the symptoms identified occurred within a few hours of the diagnosis of NEC (determined by the time gastric decompression began). 

To me, one of the most interesting associations found was that 38% of the infants in this study had received a blood product within 48 hours of the diagnosis of NEC.  The authors do not differentiate between early and late NEC, but in another publication (Christensen) by the same authors, they report 40 infants developed NEC after a blood transfusion Vs 72 that developed NEC unrelated to blood transfusion.  They note that those that had NEC post transfusion were older (mean day of life 23 Vs 16) had received larger volumes of feeds and suggest possibly altering feeding practices before and during blood transfusion in the growing premature infant.

This association has been reported elsewhere by Mally et. Al with a similar percentage (35%) of surgical NEC cases receiving blood transfusion within 48 hours of diagnosis.  The time (hours) from transfusion to diagnosis is similar to the above reports.  These were also “older” premature infants that were considered stable, growing infants on full feedings.

Whether blood transfusions are a cause of late NEC, or an association, we should all be aware of this finding and evaluate the need for what has become a routine practice.  We should also be diligent in critically assessing the need for the many blood tests ordered that lead to the need for transfusion.

“Transfusion and NEC: Is there a connection?” is a “Hot Topic” at the Children’s Hospital at Dartmouth hosted Neonatal Advanced Practice Nursing Forum this week and is presented by Roger Soll, MD.  If you attended this session at the conference, post a response – or if you have changed your practices regarding feedings and blood transfusions, post a comment.

Mindy Morris RN

Additional Comments: 

June 2, 2010
23:34

To comment on this article, Select Submit Comments.

Return to top