A 5-day-old boy in the neonatal intensive care unit is evaluated for sudden-onset vomiting. The patient was born at 32 weeks gestation via vaginal delivery. Since birth, he has tolerated a mixture of expressed breast milk and preterm cow's milk-based formula administered via nasogastric tube. The patient has had emesis with the last 3 feeds; the first two were green, and the last had a coffee-grounds appearance. Temperature is 37.5 C (99.5 F). Vital signs reveal mild tachycardia. Physical examination shows a drowsy but arousable infant. The abdomen is moderately distended and appears tender to palpation. Bowel sounds are decreased. Abdominal radiograph reveals pneumatosis intestinalis. What is the best next step in management of this patient?

Question

A 5-day-old boy in the neonatal intensive care unit is evaluated for sudden-onset vomiting.  The patient was born at 32 weeks gestation via vaginal delivery.  Since birth, he has tolerated a mixture of expressed breast milk and preterm cow's milk-based formula administered via nasogastric tube.  The patient has had emesis with the last 3 feeds; the first two were green, and the last had a coffee-grounds appearance.  Temperature is 37.5 C (99.5 F).  Vital signs reveal mild tachycardia.  Physical examination shows a drowsy but arousable infant.  The abdomen is moderately distended and appears tender to palpation.  Bowel sounds are decreased.  Abdominal radiograph reveals pneumatosis intestinalis.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d686_8650_bc81_fd3c62c7c5a2_MD0003_00 Pneumatosis intestinalis refers to air in the bowel wall and is the hallmark x-ray finding in necrotizing enterocolitis (NEC). NEC is a potentially life-threatening condition that occurs primarily in premature and very-low-birth-weight infants due to the invasion of gas-producing bacteria in the gut mucosal wall. Intestinal inflammation and necrosis cause feeding intolerance (eg, gastric residuals, bilious emesis), a tender and distended abdomen, and gastrointestinal (GI) bleeding (eg, hematochezia, hematemesis), as seen in this patient. Without prompt recognition and treatment, progressive infection can lead to septic shock, bowel perforation, and death. x-ray Intestinal inflammation and necrosis Immediate management of NEC includes bowel rest (ie, discontinuation of enteral feeds, gastric decompression, parenteral nutrition), intravenous fluids, and empiric broad-spectrum antibiotics. Because bacteremia is common with NEC, blood cultures should ideally be obtained prior to administering antibiotics to help guide therapy. Response to therapy is monitored closely via serial blood work, abdominal examinations, and imaging. Surgical intervention (eg, laparotomy) is reserved for patients with bowel perforation (ie, free intraperitoneal air) or clinical deterioration (eg, vital sign instability, persistent acidosis) despite medical management (Choice C). (Choice B) Although premature infants fed breast milk have a decreased risk of developing NEC compared to those who are formula-fed, treatment of NEC requires complete bowel rest, with discontinuation of all enteral feeds. (Choice D) Antenatal corticosteroids are often administered to mothers at risk for preterm delivery to aid in fetal lung maturity. Corticosteroids are not part of NEC management. (Choice E) Upper GI endoscopy can be used to evaluate for a GI bleed in a patient with hematemesis. However, this patient's x-ray findings are diagnostic of NEC, making endoscopic intervention unnecessary at this time. Educational objective: Necrotizing enterocolitis is a life-threatening condition that causes feeding intolerance, abdominal distension, gastrointestinal bleeding, and pneumatosis intestinalis (air in bowel wall) in premature infants. Initial management is bowel rest, in addition to blood cultures and empiric antibiotics. References: Necrotizing enterocolitis. (http://www.ncbi.nlm.nih.gov/pubmed/29196510)

A 5-Day-Old Boy in the Neonatal Intensive Care Unit Is