Case Study: NEC Brittney Hudson BYU

Patient Profile IL Female Born at 26 2/7 weeks due to premature rupture of membranes in the mother

Necrotizing Enterocolitis (NEC) Acute inflammatory disease occurring in the intestines of premature infants Cause is unknown Intestinal immaturity Abnormal microbial intestinal colonization Highly dysregulated immunoreactive intestinal mucosa Gastric acid secretions Inflammation Decreased blood flow to intestines

Clinical Features, Signs and Symptoms Doesn’t occur until about 2 weeks after birth Feeding intolerance Abdominal distention Bloody stools Bilious emesis Pneumatosis intestinalis Pneumoperitoneum

Tests to diagnose Imaging studies Laboratory tests C-reactive protein White blood cell count Platelet count

General Treatment Recommendations Decompress bowel Antibiotics Surgery Necrotic bowel resected Colostomy Ileostomy Bowel rest

Effect on Nutritional Status Malabsorption and malnutrition Bowel rest TPN Bloody stool  anemia Bowel resection Steroids

IL’s Story Bloody stools DOL #12 Transferred to PCMC Intubated TPN PRBC transfusions

Surgery Subtotal colectomy with end ileostomy placement Almost entire small bowel healthy and viable Colon necrotic from the cecum to the mid sigmoid colon 15 centimeters resected – including ileocecal valve

Medications Dexamethasone and hydrocortisone Impaired wound healing Elevated blood sugar Decreased weight gain

Anthropometrics Birth weight 900 grams Reference weight: 930 grams 1000 grams 1100 grams

DateReference Weight PercentileReal Weight Percentile Length PercentileOFC Percentile 4/2115%50%-- 4/2810%35%<3%8% 5/5Not used anymore8%<3%

Biochemical LFTs and alkaline phosphatase – WNL Conjugated bilirubin – WNL Urine Iodine – low (33 mcg/L) – added to TPN Copper – low (52 ug/dL) – added to TPN Carnitine - WNL

Dietary TPN Fluid restriction Concentrated EN On and off Neocate or Breastmilk 20kcal/oz

Determination of Risk High risk Prematurity NEC Nutrition Support Nutrition Diagnosis Altered GI function related to alteration in GI anatomical structure (NEC requiring subtotal colectomy and end ileostomy placement) as evidenced by need for TPN and IL for nutrition support.

MNT Plan Adjust nutrition support as necessary to support weight gain of gm/kg/d. Advance enteral feedings of breastmilk or Neocate 20kcal/oz as tolerated and medically indicated Initiate PO feedings

Recommendations Made Labs Adjustments to TPN based on labs and growth Concentration Adjust reference weight

Monitoring and Evaluation Growth Weight Length OFC Labs Infusion of nutrition support Concentration