Elsevier

Early Human Development

Volume 83, Issue 10, October 2007, Pages 635-642
Early Human Development

Prevention and treatment of necrotising enterocolitis in preterm neonates

https://doi.org/10.1016/j.earlhumdev.2007.07.007Get rights and content

Abstract

Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.

Section snippets

Pathogenesis of NEC

Despite decades of research the pathogenesis of NEC continues to be poorly understood. Prematurity however continues to be accepted as the single most important risk factor for the illness. An interplay of various risk factors including hypoxia, formula feeding, sepsis and intestinal ischemia–reperfusion (I–R) injury against the background of a vulnerable gut is proposed to contribute to the inflammatory cascade that in some situations precipitates NEC [9]. Currently tumor necrosis factor alpha

Aim and methods

The following systematic review is aimed to derive evidence-based best practice guidelines for the prevention and treatment of NEC. The focus is on simple, inexpensive, and readily available strategies that can be implemented with ease (Table 1). Directions for future research are provided. For the literature review the data bases Medline, EMBASE, CINAHL, the Cochrane Library, reference lists of review articles, and abstracts published in Pediatric Research from 1970 onwards were reviewed in

Antenatal glucocorticoids

A significant reduction in the incidence of NEC following antenatal glucocorticoid therapy (AGT) was first reported in 1984 by Bauer et al. [10]. The protective effect of AGT on NEC was more dramatic than that on the primary outcome (respiratory distress syndrome) for which the multicentre trial was designed [NEC: 2% (6/307) vs 7.1% (21/297), p = 0.002). The protective effect persisted even after comparison by gestation age, birth weight, and complications [10]. A meta analysis by Crowley et al.

Standard of care

The overall standard of care provided to neonates with NEC is important in the prevention and prompt correction of metabolic derangement (MD) such as hyponatremia, hypotension, and metabolic acidosis. Tepas et al. have reported MD as the best predictor of mortality (OR: 4.76; CI: 1.41–16.13, p = 012) in NEC, which significantly increased with extending interval between diagnosis to surgery. Neonates with MD receiving peritoneal drain had a 4-fold increase in mortality (OR: 4.43; CI: 1.37–14.29; p =

Summary

Prevention and treatment of NEC has become an area of priority for research due to the significant mortality and morbidity (including long-term NDI) related to the illness. Given that progression of the illness from stage II to stage III (perforation and peritonitis) is associated with most of the mortality and morbidity, secondary prevention of NEC is equally important. The role of inflammatory mediators in the pathogenesis of the illness supports immunomodulator therapy as an attractive

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