Multi-modal approach to prophylaxis of necrotizing enterocolitis: clinical report and review of literature

For the first time a multimodal approach to NEC prophylaxis is reported, consisting of early trophic feeding with human breast milk, and enteral administration of an antibiotic, an antifungal agent, and probiotics. A retrospective analysis of local protocol of NEC prophylaxis is presented. Included were all VLBWI admitted to the NICU, including transfers within the first 28 days of life. These infants were divided into two groups, an "inborn group" (infants admitted within the first 24 h of life) and an "outborn group" (infants admitted after the onset of their second day of life). Prophylaxis of NEC according to protocol was started at the day of admission, and was continued until discharge. Between 1998 and 2004, 405 VLBWI were admitted, including all transfers within the first 28 days of life. A total of 334 (82%) infants were admitted within the first 24 h of life (inborn group), and 71 (18%) were admitted after 24 h of life (outborn group). Five infants developed clinical features of necrotizing enterocolitis. The inborn group showed a NEC incidence of 0.7% (two infants), whereas the outborn group showed a NEC incidence of 4.5% (three infants), respectively. This difference was significant (P=0.049, Fisher's exact test). A surgical treatment with bowel resection was performed in two infants (both from the outborn group). The present study used a combination of different strategies, all having shown to have some beneficial effect, but not having brought a clinical breakthrough in single administration studies. Combinated were the beneficial effects of human breast milk feeding, oral antiobiotics, oral antifungal agents, and the administration of probiotics. In a homogenous group of preterm infants, using this protocol of multimodal NEC prophylaxis, there was a very low incidence of NEC, when started within the first 24 h of life.

Spontaneous gastrointestinal perforation in very-low-birth-weight infants--a rare complication in a neonatal intensive care unit

Over a 6-year period (1989-1995), gastrointestinal (GI) perforation was diagnosed in nine preterm infants (mean gestational age 27 weeks, mean birth weight 872 g). Three presented with necrotizing enterocolitis (NEC), two with indwelling-tube-induced perforation of the stomach, one with small-left-colon syndrome, and another with meconium ileus. Spontaneous intestinal perforation occurred in two similar very-low-birth-weight (VLBW) infants, in the distal ileum, on days 8 and 9 of life, respectively. The only clinical sign was extensive abdominal distension, and abdominal X-ray studies revealed free peritoneal air. All findings were distinct from those associated with NEC. Their further clinical course was complicated by reperforation on day 32 and 39, respectively. They subsequently recovered and presented without GI problems at the corrected ages of 4 and 2 months, respectively. In contrast to high mortality of 57% in the group with non-spontaneous intestinal perforations, spontaneous perforation seems to have a good prognosis even in VLBW infants if diagnosed and treated promptly.

Neurodevelopmental outcome of hydrocephalus following intra-/periventricular hemorrhage in preterm infants: short- and long-term results

Over a 5-year period (1984-1988) intra- and periventricular hemorrhage (IVH/PVH) was observed in 299 preterm infants. Sixty-eight infants developed posthemorrhagic hydrocephalus (PH); of these, 23 infants died and 40 infants could be followed up for assessment of neurological development (5 patients were lost to follow-up). At 1 year of corrected age 15% (25% at 5 year follow-up) of the infants were determined to have developed normally, 35% (25% at 5-year follow-up) showed mild neurological symptoms and/or slight developmental delay, 32.5% (28% at 5-year follow-up) had handicaps and/or moderate mental retardation, and 17.5% (22% at 5-year follow-up) had severe handicaps and/or severe mental retardation. There was a significantly worse outcome in infants with grade 4 IVH/PVH (P < 0.05) and a significantly worse outcome in the group requiring ventriculoperitoneal (VP) shunt (P < 0.05). The results at 1 year of corrected age proved to be a quite realistic predictor of neurological functioning at 5 years of age (80% predicted correctly in the non-shunted-group--one patient lost to follow-up; 95% predicted correctly in the shunted group--four patients lost to follow-up). Cystic periventricular leukomalacia had been diagnosed in 7 (10%) patients and was associated with poor neurodevelopmental outcome. Gestational age, birth weight, time of shunt placement, and peripartum asphyxia had no significant influence on neurodevelopmental outcome. Infants with shunt infections and a high number of shunt revisions were found to have a significantly worse neurodevelopmental outcome (P < 0.01).

[An asphyctic newborn infant with sonographically dilated ventricles]

Brain edema causes severe cerebral defects after perinatal asphyxia. In managing children with asphyxia adequate therapy of brain edema is most important for the neurological outcome. Usually estimation of the width of the ventricular system is initially used for sonographical classification or suspicion of brain edema. We present a case with the unusual aspect of wide cerebral liquor system in spite of severe asphyxia and severe brain edema with consecutive cerebral atrophy. In this case brain edema could only be recognised by the use of doppler sonography of the cerebral vessels and was confirmed by brain pressure monitoring. We therefore suggest that sonographic diagnostic workup of newborns with asphyxia must include a doppler-sonography of the cerebral vessels as well as a brain pressure monitoring.

The influence of head position on the intracranial pressure in preterm infants with posthemorrhagic hydrocephalus

In order to measure the intracranial pressure (ICP) of 8 newborn with posthemorrhagic hydrocephalus (group A) we used the noninvasive technique via the anterior fontanel (Ladd monitor). The ICP was monitored in two different head positions (30 degrees elevated, horizontal). The median measurements were: elevated head position, 13 mm Hg, horizontal head position, 16 mm Hg. For comparative reasons, we also measured the ICP of 12 healthy newborns (group B). The median results were: elevated head position, 4 mm Hg, horizontal head position, 6.5 mm Hg. Significant differences were found between groups.

Endoscopic evacuation of an intracerebral and intraventricular haemorrhage

An intracerebral and intraventricular haemorrhage associated with acute post-haemorrhagic ventricular dilatation was evacuated under endoscopic view in a 9 day old preterm infant. Ventricular dilatation was arrested, but a moderate left spastic hemiparesis remained. The physical and mental development of the baby was normal.

[Life-threatening hypernatremia caused by faulty preparation of fully adapted infant formula]

Two male newborns developed severe life threatening hypernatremia with serum sodium levels of 181 and 196 meq/l respectively. Both children were fed a two-to fivefold concentrated powdered infant formula since birth. Shortly before admission diarrhea developed in both patients. The children were admitted during the third week and fourth week respectively, of their lifes with clinical signs of severe hyperosmolar dehydration. In both, treatment of shock was instituted and was followed by rehydration therapy. Great care was taken to lower serum sodium by not more than 15 meq/l/day in order to prevent cerebral edema. Inspite of these measures, the first patient developed cerebral seizures 5 hours after initiation of fluid replacement. The patient was intubated, and measures aimed at prevention of cerebral edema were started (hyperventilation). The eventual outcome was satisfactory, on follow up the patient showed no signs of persistent cerebral damage. In the second patient the same management was started from the beginning and no cerebral problems occurred. Restoration of stable body functions with a normal electrolyte status was achieved within five days.