Elsevier

The Lancet

Volume 368, Issue 9543, 7–13 October 2006, Pages 1271-1283
The Lancet

Seminar
Necrotising enterocolitis

https://doi.org/10.1016/S0140-6736(06)69525-1Get rights and content

Summary

Necrotising enterocolitis is one of the most common gastrointestinal emergencies in newborn infants. Here we review the epidemiology, clinical presentation, and pathophysiology of the disease, as well as strategies for diagnosis, management, and prevention. Necrotising enterocolitis is one of the most devastating and unpredictable diseases affecting premature infants. Despite decades of research, its pathogenesis remains unclear; diagnosis can be difficult; and treatment is challenging. We will need to improve our understanding of intestinal defences in premature infants, dietary and bacterial factors, and genetic effects that could predispose infants to necrotising enterocolitis before we can develop new strategies for prevention and treatment.

Introduction

Necrotising enterocolitis is one of the most common gastrointestinal emergencies in newborn infants. First described over a century ago, this disease remains an enigma. Pathogenesis is still unproven; treatment is difficult and often proves inadequate; and no effective prevention strategy has been agreed. The disease is especially poignant because it mainly affects premature infants who have survived the early neonatal period and subsequently face a disease with high morbidity and mortality. We also note that spontaneous intestinal perforation has become an increasingly common gastrointestinal emergency in preterm infants. Although the emergence of this disorder is of concern, it probably represents a separate disease entity that is beyond the scope of this Seminar.

Section snippets

Epidemiology

Although multiple case-control studies have attempted to identify demographic or clinical risk factors (or both) for the development of necrotising enterocolitis, prematurity and low birthweight are the most consistently recorded risk factors. Over 90% of infants who develop the disease are born preterm, and the risk is inversely related to birthweight and gestational age.1, 2, 3, 4, 5 Advances in obstetric and neonatal care have improved survival rates for smaller, more immature infants, and

Pathophysiology

The pathophysiology of necrotising enterocolitis remains poorly understood. Premature infants are at high risk because of developmental immaturity of key functions, in particular gastrointestinal motility, digestive ability, circulatory regulation, intestinal barrier function, and immune defence. Other potential contributing factors include hypoxic-ischaemic injury, feeding with formula milk, and colonisation by pathological bacteria (figure 1).1, 40

Clinical presentation

Necrotising enterocolitis presents with both gastrointestinal and systemic signs.13, 133 Age at presentation is inversely related to gestational age at birth,2, 134 with full-term infants often presenting in the first few days of life.29, 135 Neonates most commonly present with feeding intolerance, delayed gastric emptying, abdominal distention or tenderness (or both), occult or gross blood in the stool, lethargy, apnoea, respiratory distress, or poor perfusion. Because early signs of this

Diagnosis and management

When necrotising enterocolitis is clinically suspected, radiological and laboratory studies should be obtained to confirm the diagnosis and to aid in management (figure 6). Clinicians examine serial abdominal films (supine anterioposterior view) for signs of the disease. A horizontal view can reveal free air (supine cross-table lateral or a left-side down decubitus). Early non-specific signs include diffuse distention and asymmetric bowel gas pattern. Definite signs include pneumatosis

Prevention

Strategies to prevent necrotising enterocolitis should improve both short-term and long-term outcomes for VLBW preterm infants (panel 2). Feeding of human milk and conservative feeding practices, especially in infants suspected to be at higher risk, can reduce the incidence of the disease.6, 7, 150 However, researchers do not agree on whether human milk from a donor is as protective as mother's milk.8, 151 Antenatal steroids,110 IgA supplementation,152, 153 arginine supplementation,154

Search strategy and selection criteria

We searched the Cochrane Library (1980 to present) and MEDLINE (1980 to present) using the search terms “necrotizing enterocolitis” or “NEC”. We selected articles published in English, focusing on publications from the past 5 years, but including older publications that are commonly referenced or highly regarded. We also searched the reference lists of articles identified by this search strategy and selected additional publications that we judged relevant. Several reviews and book

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