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Necrotizing enterocolitis (NEC) is the most common and serious gastrointestinal emergency in newborn infants. The pathophysiologic mechanisms leading to NEC are complex and somewhat elusive. It is characterized by severe inflammation of the intestinal mucosa, invasion of enteric bacteria, and gas dissection that can extend into the portal venous system, potentially resulting in perforation. Associated intestinal ischemia can lead to extensive ischemic necrosis in severe cases.
The clinical presentation of NEC can vary. It may begin subtly with simple abdominal distension and progress insidiously, or it can present abruptly with rapid intestinal necrosis, leading to cardiovascular and respiratory collapse.
The most significant risk factor for developing NEC is prematurity. The incidence of NEC is inversely proportional to gestational age at delivery, with a similar trend observed with birth weight. NEC is rare in term infants and usually associated with congenital anomalies affecting intestinal development or perfusion, such as congenital heart disease.
Despite advancements in neonatal care, morbidity and mortality related to NEC remain significant. Medical treatment is largely supportive, focusing on bowel rest, intestinal decompression, antibiotics, cardiorespiratory support, and parenteral nutrition. Surgical intervention may be required for intestinal necrosis or perforation. Mortality rates for those requiring surgery can be as high as 50%. Survivors may face complications such as short bowel syndrome, intestinal strictures, cholestasis, failure to thrive, and neurodevelopmental delays.
NEC is a multifactorial problem with several identified risk factors. While some, like maternal morbidities and genetic predisposition, cannot be modified, others can be addressed:
Probiotics have shown promise in NEC prevention by addressing intestinal dysbiosis, although safety concerns remain due to the lack of regulation and potential for sepsis in neonates (Barbian, 2023).
Recent developments in ultrasound technology have improved NEC diagnosis and monitoring. Ultrasound can detect pneumatosis, bowel wall abnormalities, and portal venous air. It can also monitor superior mesenteric artery blood flow, with certain characteristics predictive of NEC.
Near-infrared spectroscopy (NIRS) is another non-invasive method for assessing tissue oxygenation. Lower cerebral oxygen saturations in the first 48 hours of life have been associated with a higher prevalence of NEC. Research is ongoing to better understand intestinal oxygenation.
Research has identified potential biomarkers for NEC, which could facilitate earlier diagnosis and risk identification. These include:
Significant dedication to research and collaboration among disciplines has advanced our understanding of NEC. Emerging tools for early identification and prevention are promising, but continued research is essential.
Dr. Elizabeth Cristofalo, MD, MPH, is a neonatologist with training from the University of Pennsylvania, Children’s Hospital Los Angeles, and Johns Hopkins. She has served as a faculty member at Johns Hopkins and Yale University, focusing her research on breast milk and neurodevelopment of at-risk newborns.