Abstract

Necrotizing enterocolitis (NEC) affects ten percent of premature neonates with birth weight less than 1500g. This unpredictable destruction of intestine is the result of complex interactions between the immature immune system, microvasculature, and gut microbiome that remain incompletely understood. Clinically, it can present along a spectrum from mild physiologic perturbation to necrosis of the entire intestine (“NEC totalis”). Both the risk for developing NEC and the mortality rate are inversely proportional to birth weight with mortality up to 50% in 500g neonates. NEC is a clinical diagnosis, incorporating findings from plain films (pneumatosis intestinalis) and the laboratory consistent with sepsis (leukocytosis, thrombocytopenia, acidosis, etc). The mainstays of medical treatment are bowel rest, broad spectrum antibiotics, and parenteral nutrition. The only absolute indication for surgical intervention is bowel perforation, typically manifested as pneumoperitoneum, though progression of disease despite maximal medical management may also be considered grounds for operation. Two randomized controlled trials demonstrated that the selection of operative intervention, peritoneal drainage versus laparotomy, does not affect mortality and short term outcomes. A subsequent trial has completed enrollment and will report long-term neurodevelopmental outcomes. Though a variety of interventions have been studied for the prevention of NEC, only the use of breast milk over formula has been widely incorporated in NICU practice. Prophylactic probiotic administration appears to decrease the risk of NEC. A number of additional preventative strategies and probiotic delivery mechanisms are currently under study.

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