Dr AnakhaV Ajay ,Dr Jayasree, Dr Perraju DrLakshmi, Dr Ashwin Dr Smrithi (Dept of Neonatology) Dr C Jayakumar
AIMS Kochi
Three day old male neonate born to a 39 year old Gravida 4, Para 2 Living 2 Abortion 1 mother with negative serologies, whose pregnancy was complicated pregnancy induced hypertension(PIH). Ba was born at 35 weeks and 2 days of gestation via emergency caesarean section (PIH)with birth weight of 3.30 kg.. Postnatally ba was on room air. MAt 48 hours of life, ba was noted to have desaturation episodes and hence started on oxygen support via hood box.
Ba was started on direct breast feeds along with top up feeds. Ba passed meconium at 30 hours of life.
At 55 hours of life ba was noted to have abdominal distention with greenish coloured aspirates, but no blood in stools noted.
Hence ba was kept nil orally and started on IV fluids.
X-ray abdomen done and was suggestive of dilated bowel loops.
Septic screen was sent and showed raise CRP hence ba was started on IV Ampicillin and IV Metrogyl. Ba was referred to our institute for further management.
On examination- Ba had stable vitals with saturation maintaining at room air. No obvious external anomalies noted Respiratory system examination revealed Air entry present bilateral with transillumination negative.Minimal subcostal retractions present
Abdomen examination showed distended and tense abdomen with good bowel sounds heard. No organomegaly noted. Other systemic examination were found to be within normal limits.
Differentials considered were:
1.NEC
2. Perforation of bowel
3. Intestinal obstruction
Ba was started on nasal cannula with flow of two litres as ba had minimal respiratory distress.
Ba started to develop recurrent episodes of apnea after admission.
Ba was electively ventilated and put on SIMV mode and sedated with morphine. Ba was also noted to have severe abdominal distention with greenish coloured nasogastric aspirates. Xray abdomen done was suggestive of stage 1 NEC and ruled out perforation.Ba was initially kept NPO and started on total parenteral nutrition. Blood sugars monitored were normal. In view of presumed sepsis, blood culture was taken and ba was started on IV Meropenem, Inj Amikacin and Inj metronidazole. Sepsis screen was suggestive of raised CRP. Prophylactic antifungals were given In view of central line insitu
ECHO was done to rule out any ventricular dysfunction and was normal.
Ba was extubated on day 5 of admission to HFNC support and then to room air on on day 6 of admission Ba was kept NPO for 12 days and then feeds were started from day 14 of life.
NSG no periventricular leukomalacia
Antibiotics were stopped after 14 days. Repeat CRP was in the decreasing trend. Ba improved clinically and tolerated feeds well, hence was discharged.
XRAY ABDOMEN SHOWING
DILATED BOWEL LOOPS
Necrotising Entercolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant.
Incidencec1 to 3 per 1000 live births. More than 90 percent of cases occur in very low birth weight infants (<1500 g) born at less than 32 weeks gestation, and the incidence of NEC decreases with increasing gestational age and birth weight. It presents with sudden changes in feeding tolerance,and systemic signs (apnea,respiratory failure, poor feeding, lethargy, or temperature instability) and abdominal signs (abdominal distension, bilious gastric retention and/or vomiting, tenderness, rectal bleeding, and diarrhoea). Physical findings may include abdominal wall erythema, crepitus, and induration. A clinical diagnosis of NEC is based on the presence of the characteristic clinical features of abdominal distension, bilious vomiting or gastric aspirate, and rectal bleeding (haematochezia), and the abdominal radiographic finding of pneumatosis intestinalis, pneumoperitoneum, or sentinel loops.
Bell staging criteria, which stages
NEC based upon the severity of clinical findings Medical management should be initiated promptly when NEC is first suspected. Supportive care includes – Stabilization of the neonate’s cardiopulmonary status, Bowel rest with discontinuation of enteral intake, Gastric decompression with intermittent nasogastric suction, Initiation of parenteral nutrition, Correction of metabolic, fluid or electrolyte, and hematologic abnormalities
For all infants with suspected or established NEC, it is suggested to initiating of antibiotics after obtaining appropriate specimens for culture Patients with intestinal perforation and/or clinical deterioration despite optimal medical management require surgical intervention.
The prognosis for infants with NEC has improved with earlier recognition and treatment. Survival rates range from 70 to 80 percent. The risk of mortality increases with decreasing gestational age.
TAKE HOME MESSAGE: Timely and effective intervention improves outcomes and can be crucial in managing this serious condition.