A 2-week-old girl in the neonatal intensive care unit for prematurity is evaluated for increasing episodes of apnea and bradycardia over the past 3 hours. The patient was born at 29 weeks gestation via vaginal delivery; birth weight was 1.02 kg (2 lb 4 oz). She has been receiving enteral feeds via nasogastric tube with premature formula. Temperature is 36.1 C (97 F), blood pressure is 76/42 mm Hg, pulse is 150/min, and respirations are 44/min. Pulse oximetry is 96% on room air. The patient appears lethargic. There is no cyanosis, stridor, or intercostal retractions. The lungs are clear to auscultation bilaterally. Heart sounds are normal with no gallops or heart murmur. There is mild abdominal distension. The extremities are well perfused. Laboratory results are as follows: Which of the following is the best next step in management?

Question

A 2-week-old girl in the neonatal intensive care unit for prematurity is evaluated for increasing episodes of apnea and bradycardia over the past 3 hours.  The patient was born at 29 weeks gestation via vaginal delivery; birth weight was 1.02 kg (2 lb 4 oz).  She has been receiving enteral feeds via nasogastric tube with premature formula.  Temperature is 36.1 C (97 F), blood pressure is 76/42 mm Hg, pulse is 150/min, and respirations are 44/min.  Pulse oximetry is 96% on room air.  The patient appears lethargic.  There is no cyanosis, stridor, or intercostal retractions.  The lungs are clear to auscultation bilaterally.  Heart sounds are normal with no gallops or heart murmur.  There is mild abdominal distension.  The extremities are well perfused.  Laboratory results are as follows:  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d71d_964f_bc81_bd16cd54b2a4_MD0003_00 This preterm infant's increasing apnea and abdominal distension are concerning for necrotizing enterocolitis (NEC), a life-threatening condition characterized by intestinal inflammation and necrosis due to gas-producing bacteria. Premature (especially gestational age <32 weeks) and very-low-birth-weight neonates receiving enteral feeds, particularly with formula, are at greatest risk for NEC; a high degree of suspicion is required in these infants because initial findings may be subtle but can lead to rapid clinical deterioration. Presentation can occur weeks after birth and is often nonspecific, including apnea, lethargy, feeding intolerance, or vital sign instability (eg, hypothermia). The abdomen is typically distended and can become tense and erythematous. Laboratory evaluation is also nonspecific, and the leukocyte count may be normal, low, or elevated. Notably, thrombocytopenia and metabolic acidosis are associated with advanced disease. tense and erythematous The next step in evaluation of suspected NEC is an abdominal x-ray; pneumatosis intestinalis (ie, air in the bowel wall) is diagnostic. NEC complicated by intestinal perforation reveals pneumoperitoneum (ie, free air under the diaphragm) on x-ray and is an indication for surgery. pneumatosis intestinalis (Choice B) Increasing apnea in a premature neonate can be a sign of heart failure due to a patent ductus arteriosus. Echocardiography may be indicated if cardiac or pulmonary findings, such as a murmur, crackles, and respiratory distress, are present. However, this patient's abdominal distension and normal cardiopulmonary examination make NEC more likely than a cardiac etiology. (Choice C) Although endotracheal intubation may be required for sustained apnea, it is not currently indicated in this neonate with normal oxygenation and no signs of respiratory distress (eg, no stridor or retractions). (Choice D) Metoclopramide may be used in adults to treat gastroparesis, which can cause abdominal distension due to delayed gastric emptying. This medication is not used to treat NEC, in which bacterial translocation into the intestinal wall warrants antibiotic (not prokinetic) therapy. (Choice E) Apnea of prematurity is common in preterm infants due to immature respiratory drive and can often be observed or treated with caffeine. However, onset is typically in the first few days of life; increasing, new-onset apneic episodes, especially in combination with abdominal distension, require further evaluation. Educational objective: Necrotizing enterocolitis should be suspected in an enterally fed, premature or very-low-birth-weight infant with nonspecific apnea, lethargy, and abdominal distension. Pneumatosis intestinalis on abdominal x-ray is diagnostic. References: Necrotizing enterocolitis. (http://www.ncbi.nlm.nih.gov/pubmed/29196510)

A 2-Week-Old Girl in the Neonatal Intensive Care Unit for Prematurity