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Overview on necrotising enterocolitis
EHD-04254; No of Page 1 Early Human Development xxx (2016) xxx
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Overview on necrotising enterocolitis
Necrotising Enterocolitis (NEC) is an extensively studied disease from a basic sciences point of view as well as clinically. In spite of this intense focus on NEC, the incidence, morbidity and mortality in NEC have not decreased over the years. This special issue on NEC covers medical management, surgical management and long term outcomes, management of intestinal failure post NEC and current research in NEC. The first article describes the incidence, the current thoughts on pathophysiology and the various trials related to the aetiology of NEC. Transfusion associated NEC and the controversy is further argued. Evidence bases clinical studies for the protection against NEC on the use of antenatal steroids, judicious fluid restriction, human milk feeding, standardised feeding and probiotic supplements are well described and argued. Different facets of feeding and their relationship with risk of NEC such as gastric residue, timing of feeds, AREDF (absent-reverse end diastolic flow), umbilical artery catheters, patent ductus arteriosus (PDA) and the drugs used for PDA treatment are further discussed. In the management of NEC the limitations of the currently used Bell's criteria are mentioned, the radiological spectrum described and the medical management with supportive care and monitoring critically reviewed. Despite the advances in neonatal care approximately one third to one half of NEC diagnoses cases would necessitate surgical intervention and the mortality in those needing surgery is close to 40%. Absolute indication for surgery, namely pneumoperitoneum is well described however the timing of surgery in the ‘at risk’ infant is a subject of much discussion and research. The recent BAPS-CASS surveillance study may provide some direction. Factors identified as risk factors are described in detail. Surgical approaches are described and the risk benefit of each procedure is outlined. The debate on the usage of peritoneal drainage versus open laparotomy is well argued with the limitations of the peritoneal drainage approach. The choice of procedure is still largely dependent on the surgeon and the finding at operation. The choice of procedure in relation to the size of the baby as described in the literature is analysed. Surgical morbidity for each procedure is described in detail and the need for multidisciplinary team involvement in the management of those surviving infant at risk of gut malfunction from malabsorption or short gut is further emphasised. The debate on the use of laparoscopy is ongoing and awaits larger studies with prospective data before laparoscopy becomes standardised as a surgical approach in the management of NEC. There is a paucity of data on the long-term
outcomes of NEC. Two long term studies identified in the literature on cognitive behaviour and neurodevelopment respectively are described. Further long-term cognitive data from the NEST trial is awaited. High mortality with NEC in newborns is well known but the aftermath of the surviving infant with gut failure is not without its challenges and cost. The most common morbidity post-surgical NEC survival is gut failure either due to malabsorption or short gut. Howarth et al. in this series of articles have outlined a clinical approach to the management of these difficult infants. The aim of early nutritional and physiological support is well outlined with the aim of making the infant free of parenteral feeding. Morbidity from parenteral nutrition (PN) related to infection and liver insult is further outlined with the benefit of fish oil based PN. The type, rate and volume of enteral feeding are recommended for gut adaptation and protection. Transition from post-NEC to intestinal failure is well described incorporating gut motility, nutrition, infection, line care and liver protection. Where medical support fails surgical input with gut lengthening procedures should not be ignored before the ultimate offer of transplantation. Limitation of animal models and the difficulty in translation of basic science studies into clinical settings has recently steered research on NEC into mainly clinical research studies in parallel with basic sciences. Current research into the main factors involved in the pathogenesis of NEC such as intestinal immaturity, enteral feeds, the intestinal microbiome, inflammation and local ischaemia and/or reperfusion injury are discussed. Researches have been attracted to the clinical utility and research into biomarkers and the role of ultrasound for the diagnosis of NEC. Near infra-red spectroscopy (NIRS) is presently being investigated as a possible tool for predicting risk of NEC. Research into prevention of NEC are further described focusing on therapy such as type of feeds, probiotics, antimicrobials, amniotic fluid, epidermal growth factor and further more. Kokila Lakhoo⁎ Department of Paediatric Surgery, Oxford University Hospitals, University of Oxford, Headley Way, Oxford OX3 9DU, United Kingdom E-mail address: [email protected].
http://dx.doi.org/10.1016/j.earlhumdev.2016.03.006 0378-3782/© 2016 Published by Elsevier Ireland Ltd.
Please cite this article as: K. Lakhoo, , Early Hum Dev (2016), http://dx.doi.org/10.1016/j.earlhumdev.2016.03.006
Available online xxxx
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Overview on necrotising enterocolitis
Necrotising Enterocolitis (NEC) is an extensively studied disease from a basic sciences point of view as well as clinically. In spite of this intense focus on NEC, the incidence, morbidity and mortality in NEC have not decreased over the years. This special issue on NEC covers medical management, surgical management and long term outcomes, management of intestinal failure post NEC and current research in NEC. The first article describes the incidence, the current thoughts on pathophysiology and the various trials related to the aetiology of NEC. Transfusion associated NEC and the controversy is further argued. Evidence bases clinical studies for the protection against NEC on the use of antenatal steroids, judicious fluid restriction, human milk feeding, standardised feeding and probiotic supplements are well described and argued. Different facets of feeding and their relationship with risk of NEC such as gastric residue, timing of feeds, AREDF (absent-reverse end diastolic flow), umbilical artery catheters, patent ductus arteriosus (PDA) and the drugs used for PDA treatment are further discussed. In the management of NEC the limitations of the currently used Bell's criteria are mentioned, the radiological spectrum described and the medical management with supportive care and monitoring critically reviewed. Despite the advances in neonatal care approximately one third to one half of NEC diagnoses cases would necessitate surgical intervention and the mortality in those needing surgery is close to 40%. Absolute indication for surgery, namely pneumoperitoneum is well described however the timing of surgery in the ‘at risk’ infant is a subject of much discussion and research. The recent BAPS-CASS surveillance study may provide some direction. Factors identified as risk factors are described in detail. Surgical approaches are described and the risk benefit of each procedure is outlined. The debate on the usage of peritoneal drainage versus open laparotomy is well argued with the limitations of the peritoneal drainage approach. The choice of procedure is still largely dependent on the surgeon and the finding at operation. The choice of procedure in relation to the size of the baby as described in the literature is analysed. Surgical morbidity for each procedure is described in detail and the need for multidisciplinary team involvement in the management of those surviving infant at risk of gut malfunction from malabsorption or short gut is further emphasised. The debate on the use of laparoscopy is ongoing and awaits larger studies with prospective data before laparoscopy becomes standardised as a surgical approach in the management of NEC. There is a paucity of data on the long-term
outcomes of NEC. Two long term studies identified in the literature on cognitive behaviour and neurodevelopment respectively are described. Further long-term cognitive data from the NEST trial is awaited. High mortality with NEC in newborns is well known but the aftermath of the surviving infant with gut failure is not without its challenges and cost. The most common morbidity post-surgical NEC survival is gut failure either due to malabsorption or short gut. Howarth et al. in this series of articles have outlined a clinical approach to the management of these difficult infants. The aim of early nutritional and physiological support is well outlined with the aim of making the infant free of parenteral feeding. Morbidity from parenteral nutrition (PN) related to infection and liver insult is further outlined with the benefit of fish oil based PN. The type, rate and volume of enteral feeding are recommended for gut adaptation and protection. Transition from post-NEC to intestinal failure is well described incorporating gut motility, nutrition, infection, line care and liver protection. Where medical support fails surgical input with gut lengthening procedures should not be ignored before the ultimate offer of transplantation. Limitation of animal models and the difficulty in translation of basic science studies into clinical settings has recently steered research on NEC into mainly clinical research studies in parallel with basic sciences. Current research into the main factors involved in the pathogenesis of NEC such as intestinal immaturity, enteral feeds, the intestinal microbiome, inflammation and local ischaemia and/or reperfusion injury are discussed. Researches have been attracted to the clinical utility and research into biomarkers and the role of ultrasound for the diagnosis of NEC. Near infra-red spectroscopy (NIRS) is presently being investigated as a possible tool for predicting risk of NEC. Research into prevention of NEC are further described focusing on therapy such as type of feeds, probiotics, antimicrobials, amniotic fluid, epidermal growth factor and further more. Kokila Lakhoo⁎ Department of Paediatric Surgery, Oxford University Hospitals, University of Oxford, Headley Way, Oxford OX3 9DU, United Kingdom E-mail address: [email protected].
http://dx.doi.org/10.1016/j.earlhumdev.2016.03.006 0378-3782/© 2016 Published by Elsevier Ireland Ltd.
Please cite this article as: K. Lakhoo, , Early Hum Dev (2016), http://dx.doi.org/10.1016/j.earlhumdev.2016.03.006
Available online xxxx