Twin ‘connection’ with NEC

June 21st, 2012 by Dr. Jae H. Kim (MD, PhD, FRCPC, FAAP)

The reason why we see so many twins with NEC reflect a couple of things.The most important is the link between preterm birth and twins. Having multiple births puts you at higher risk of delivering preterm. The second issues is that twins sometimes can share a blood supply between them leading to a serious problem called twin to twin transfusion syndrome. In this case both twins develop risk factors that can set them up for NEC because one twin is compromised because of too much volume while the other is disadvantaged with too little blood volume.

Preventing twin pregnancies is not easy and in fact we see more twinning occurring as a result of artificial reproductive technologies so I see the problem only getting worse before better.

An Exclusive Human Milk Diet Can Reduce Necrotizing Enterocolitis

June 4th, 2010 by Dr. Jae H. Kim (MD, PhD, FRCPC, FAAP)

The premature infant grows at an incredible rate and so plain breast milk is not sufficient to provide enough energy, protein, and vitamins to grow well.

Neonatologists add nutritional supplements in the form of a fortifier which is cow’s milk based. A recent study performed at 12 different medical centers has been able to study the effect of an exclusively human milk diet, one with not only mother’s milk but added human milk based fortifier. This study looked at 207 infants that were randomly chosen to either standard cow’s milk fortifier or a human milk based fortifier for approximately the first 90 days of life. They found that the infants who were fed an exclusively human milk diet had significantly lower incidence of NEC (50% reduction) and even more importantly had a lower rate of surgical NEC (90%).

This study supports the need for increased human milk use in the NICU and provides the first compelling data that use of a human milk based fortifier can reduce NEC.

Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr. 2010;156:562-7

Very Low Birth Weight Premature Infants are at Higher Risk of Dying With Short Bowel Syndrome

January 1st, 2009 by Dr. Jae H. Kim (MD, PhD, FRCPC, FAAP)

One of the nation’s largest premature infant databases (NICHD) has been examined to determine the risks of dying for infants with short bowel syndrome or SBS. SBS is a devastating condition where a significant portion of an infant’s small and large bowel are removed due to damage or dysfunction. Subsequently, the infant is not able to be supported nutritionally with their own bowel and require long-term intravenous nutrition. As expected from most neonatal experiences, the biggest contributor of SBS is necrotizing enterocolitis (NEC, 96%). In this study the investigators found that very low birth weight infants (less than 1500 grams at birth) who had surgical NEC were at higher risk of dying in hospital than if they had NEC without surgery (also called medical NEC) or compared to all infants with SBS. They found an overall incidence of SBS of 0.7%. They also found that the risk of dying was the highest in infant who had surgery because of NEC (53%). When they examined the outcomes of the survivors, they found that those with SBS were more likely to be small and poorly grown and this included smaller head sizes. It is important to remember that head size correlates well with long-term brain development. This study underlines the ongoing burden of the consequences of NEC on both mortality and morbidity.

Very Low Birth Weight Preterm Infants With Surgical Short Bowel Syndrome: Incidence, Morbidity and Mortality, and Growth Outcomes at 18 to 22 Months Conrad R. Cole and colleagues, for the Eunice Kennedy Shriver NICHD Neonatal Research Network, Pediatrics. 2008 Sep;122(3):e573-82.

Probiotics Can Prevent Necrotizing Entercolitis

November 1st, 2007 by Dr. Jae H. Kim (MD, PhD, FRCPC, FAAP)

Probiotics are defined as live microbes, such as bacteria, that reside in the gut and provide benefits to the person taking them. Many of us see probiotics in our daily diet such as the “live culture” bacteria found in yogurt. Several recent studies on premature babies have suggested that giving probiotics can significantly reduce the incidence of NEC (1, 2).

Interestingly, our body is composed of more bacteria cells than human cells and depends on beneficial bacteria to maintain normal health. At birth, the large bowel of term babies is quickly filled with bacteria from their mother’s colon that are normally living in the birth canal. These beneficial bacteria happily grow there and help to provide extra nutrients and boost the immune system of the individual.

Premature babies have a poorly developed bacterial colony in their large bowel. Many premature babies miss out on the early loading of beneficial bacteria by getting delivered through Cesarean section. Instead, some of these infants inherit many of the nastier bacteria found in the neonatal intensive care unit where we also inadvertently make things worse by treating babies with broad coverage antibiotics which eliminate both
harmful and beneficial bacteria. We find that the number and diversity of bacteria in their bowel do not develop to the same degree as in normal term babies.

These factors have been suggested as some of the possible reasons why premature babies develop NEC. Doctors are now finding that feeding back high amounts of “good” bacteria, ones that are normally present in the colon, on a daily basis may help temporarily promote the growth of “good” bacteria in the large bowels of vulnerable premature babies. Summarized results from
several studies support there being a strong benefit to using probiotics for premature babies to prevent NEC or reduce the severity of NEC. Infants who received probiotics had 1/3 the number of cases of NEC than those who did not. Just as important, those who receive probiotics had less severe NEC
and less death due to NEC than controls. Still, the exact effects of how probiotics work are not well understood.  Some possible effects include reduced “leakiness” of the bowel, increased immune defenses and reduced inflammation.

Summary

The use of probiotics or live beneficial microbes for premature babies is very promising in reducing the number of babies who develop necrotizing enterocolitis. Currently many questions still remain as to the best type of probiotics to use, the dosage to give, and the time and duration of the treatment. Ideally, a large multicenter study involving a couple thousand premature infants will be required for this treatment to be more broadly accepted in North America.

1. Deshpande G, Rao S, Patole S. Probiotics for prevention of
necrotising enterocolitis in preterm neonates with very low birthweight: a systematic review of randomised controlled trials. Lancet 2007;369(9573):1614-20.

2. Barclay AR, Stenson B, Simpson JH, Weaver LT, Wilson DC.
Probiotics for Necrotizing Enterocolitis: A Systematic Review. J Pediatr Gastroenterol Nutr 2007;45(5):569-576.

NEC Can Also Occur In Full Term Babies

July 1st, 2007 by Dr. Jae H. Kim (MD, PhD, FRCPC, FAAP)

A study by Lambert and colleagues (1) sought to find out reasons why some term babies may develop NEC. They looked back almost 6 years to review 30 cases of term or near-term babies in their hospital in Salt Lake City, Utah. These infants were more likely to be born with heart disease, have a high amount of red blood cells, develop early infection and have low blood pressure. All these factors affect the blood flow to the gut. When they examined the type of feeding these babies received, not a single infant was exclusively on human milk. In other words, all the babies that developed NEC were being fed formula or a mixture of formula and human milk. In this study, 13% of the babies with NEC died.

Summary: This study continues to support the belief that NEC forms as a result of some problem of blood flow to the intestine and that human milk is still the best nutrition for newborn babies. Moreover, even term infants are not immune to developing NEC.

1. Lambert DK, Christensen RD, Henry E, Besner GE, Baer VL, Wiedmeier SE, et al. Necrotizing enterocolitis in term neonates: data from a multihospital health-care system. J Perinatol 2007;27(7):437-43.