Treatment Outcomes of Necrotizing Enterocolitis for Preterm Infants Brigit M. Carter

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1 CLINICAL ISSUES Treatment Outcomes of Necrotizing Enterocolitis for Preterm Infants Brigit M. Carter Abstract : Necrotizing enterocolitis (NEC) is one of the most common life-threatening gastrointestinal emer gencies for the preterm infant. The survival rate for preterm infants after NEC has improved over the past two decades, but complications arising from medical and surgical intervention have produced many long term problems. Documented consequences of NEC include feeding intolerance and physical, developmental and cognitive problems. Bedside nurses are well positioned to detect early changes in the infant that may enable early treatment and reduce long-term complications. JOGNN, 36, ; DOI: /J x Keywords : necrotizing enterocolitis treatment outcomes neurodevelopment feeding intolerance short gut syndrome (SGS) nursing Accepted: November 2006 Continuing Nursing Education (CNE) Credit A total of 2 contact hours may be earned as CNE credit for reading Treatment Outcomes of Necrotizing Enterocolitis for Preterm Infants, and for completing an online post-test and evaluation. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABNP0058. A Glance at Treatment Outcomes of Necrotizing Enterocolitis for Preterm Infants Developmen t of sophisticated technology and therapeutic advances in neonatal intensive care units (NICU) have decreased the mortality rate of extremely and very low-birth-weight infants (McGrath & Sullivan, 2002). Yet neonatal morbidity rates have not diminished significantly (Lemons et al., 2001; Ward & Beachy, 2003 ). Premature infants continue to be at high risk for complications during hospitalization that increase the likelihood of neurodevelopmental and physical disabilities later in life. One of these complications is necrotizing enterocolitis (NEC), a multifactorial disease of the gastrointestinal system. Although the exact etiology of NEC is not completely understood, it is known that a severe inflammatory process, possibly resulting from ischemia and acidosis, makes the tissue vulnerable to infection and leads to necrosis of the bowel ( Diehl- Jones & Askin, 2004 ). Survival after NEC has improved; however, the illness and its therapy are associated with many long-term problems ( Ward & Beachy, 2003 ). Outcomes of NEC include feeding intolerance, malabsorption problems related to short gut syndrome (SGS), surgery-related complications such as strictures and obstructions, and neurodevelopmental delays that may be associated with complications from circulatory collapse pre- or postoperatively. Neonatal nurses can reduce the incidence of these complications through early detection of NEC and supportive care after diagnosis. Brigit M. Carter, RN, MSN, CCRN, is a pre-doctoral fellow at the School of Nursing, University of North Carolina at Chapel Hill. Brigit M. Carter reports no conflict of interest or relevant financial relationship. 2007, AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses JOGNN 377

2 Treatment of NEC Treatment of NEC in the preterm infant can be divided into two categories: surgical and medical. Choice of therapy for NEC is dependent on the stage of the disease based on Bell s staging criteria ( Table 1 ). Infants with vague symptoms such as apnea and bradycardia, abdominal distention and gastric residuals are often in mild stages of NEC and can be managed medically without further compromise to the bowel ( Neu, 2005 ). However, these same infants can progress without warning to more serious stages of the disease and require surgical intervention. Medical Management of NEC Medical management of NEC is directed at preventing further injury to the bowel. Protocols vary between institutions, but most include stopping enteral feeds and initiating hyperalimentation for a period of days to allow for bowel rest and recovery, replacing gastric secretions, and preventing fluid and electrolyte imbalances ( Coit, 1999 ). Gastric decompression is accomplished by placing a replogle (a firm large bore tube that allows for suction to be connected) or orogastric tube ( 8 French) and connecting them to low intermittent or continuous wall suction. Because bacterial toxins are involved in the pathogenesis of NEC, a day course of antibiotic therapy is initiated ( Lee & Polin, 2003 ). Respiratory and cardiovascular support including intubation and inotrope therapy may also be required. Serial kidney-ureter-bladder films are used to monitor for changes in bowel status (e.g., changes in gas patterns, thickening of bowel wall, or perforation), and automated blood counts with differentials are obtained to assess for rapid decreases in platelet counts, elevated white blood cell counts with bandemia and absolute neutropenia, which may indicate an inflammatory response and a potential progression of the disease state ( Henry & Moss, 2004 ). Collaboration between neonatology and surgical services is imperative to detect any overt changes in the infant s clinical status that may be evidence of progression in the stage of NEC ( Neu, 2005 ). Table 1 provides a more indepth inventory of these changes. Surgical Management of NEC Operative interventions are indicated when the bowel has perforated, if there is evidence of necrotic bowel (such as fixed bowel loops, metabolic acidosis, disseminated intravascular coagulation, or septic shock), or if the infant s condition worsens despite persistent medical management ( Caplan & Jilling, 2001 ). Surgical treatment of NEC varies depending on the presentation of NEC and may include insertion of Penrose drains or bowel removal and/or resection. Surgical treatment of necrotizing enterocolitis varies and may include insertion of Penrose drains or bowel removal and/or resection. Peritoneal drainage for isolated perforated areas of the bowel is accomplished by inserting a Penrose drain into the peritoneal cavity ( Cass et al., 2000 ). This treatment can often relieve symptoms by allowing evacuation of air and stool from the abdominal compartment, thereby improving the infant s condition enough to increase tolerance of subsequent surgical intervention. In some instances, insertion of the Penrose drain may be the only surgical treatment required. Peritoneal drainage via insertion of the penrose drain remains controversial in the extremely low birth weight (ELBW) population. It has proved successful for isolated intestinal perforations ( Ahmed, Ein & Moore, 1998; Cass et al., 2000 ). However, if the perforation is a result of NEC, this procedure is often a temporary stabilization mea sure until further surgical interventions can be perfor - med ( Ahmed et al., 1998; Cass et al., 2000; Dzakovic et al., 2001 ). Laparotomy and resection are required if insertion of the Penrose drain does not sufficiently evacuate air, pus, or stool from the abdominal compartment or if the infant s condition deteriorates (i.e. acidosis, thrombocytopenia, or inotrope therapy requirement; Ahmed, Ein, Moore, 1998). If exploratory laparotomy reveals necrotic or perforated bowel, intestinal resection is required. This is accomplished by removing the injured bowel and either externalizing the proximal bowel to form a stoma, allowing for distal bowel rest, or creating a primary anastomosis, reconnecting the proximal and distal bowel with complete abdominal closure. These two procedures have been found to have comparable complications and outcomes in the short term, but both have been associated with poor neurodevelopmental and growth outcomes ( Hofman, Bax, van der Zee, & Kramer, 2004 ). Complications of stomas include poor weight gain, electrolyte imbalances due to increased output, stenosis, prolapse, skin breakdown around the stoma site, and excoriation of the stoma itself. Although stoma formation allows for healing of the distal bowel, it also requires a second surgery for reanastomosis of the stoma and the distal bowel, which in itself can lead to further complications and lengthen hospitalization. Resection followed by primary anastomosis can be complicated by leakage of the anastomosed site and 378 JOGNN Volume 36, Number 4

3 TABLE 1 Bell s Stages of NEC Severity and Focused Nursing Interventions Stage Signs and Symptoms Treatment Nursing Interventions Stage IA (Suspected NEC) Non-specific Mild abdominal distention Apnea Bradycardia Temperature instability Lethargy Feeding intolerance (gastric residuals, emesis) Guaiac-positive stools Radiological signs: Normal or intestinal dilation, mild ileus NPO Rule out sepsis workup (blood cultures, complete blood count with differential, urine culture) IV antibiotics Replogle for bowel decompression Serial KUB films to monitor for pneumatosis or perforation Identify stressors that contribute to NEC risk (delivery, post-delivery) Monitor and report increases in apnea and/or bradycardia Insure replogle (large bore orogastric tube) is patent and is connected to suction as ordered Measure tube output and report changes in secretions Insure timely administration of antibiotics Monitor pain scores, advocate for pain medication, and administer as ordered. Narcotic drip may be indicated if condition progresses. Measure abdominal girth and report any increases or changes in color and firmness of abdomen. Monitor bowel sounds and report decreases. Guaiac all stools and report traces of blood or frank bloody stool. Provide optimal positioning for KUB to reduce need for repeated films Insure laboratory tests are ordered to monitor electrolytes. Removal of gastric secretions can cause alteration in electrolyte levels, especially potassium. Monitor EKG for changes in QRS complex that may indicate changes in electrolyte levels. Cluster care and reduce stimulation to provide periods of rest. Update family on infant s condition to decrease anxiety. (continued) July/August 2007 JOGNN 379

4 TABLE 1 (CONTINUED) Bell s Stages of NEC Severity and Focused Nursing Interventions Stage Signs and Symptoms Treatment Nursing Interventions Stage IB Suspected NEC Stage IIA Mildly Ill (Early Definitive NEC) Radiological confirmation Same as Stage IA plus frank blood via rectum. Same as Stage IA & B plus: Absent bowel sounds Abdominal distention Possible abdominal tenderness Radiological signs: Unchanging bowel loops Intestinal dilation with possible ileus Pneumatosis intestinalis Same as Stage IA Same as Stage IA Same as Stage IA plus surgical evaluation Same as Stage IA plus: Increase frequency of vital sign and pain score monitoring. Monitor respiratory status for possible need for intubation. Monitor blood gas results for acidosis due to sepsis Monitor for oliguria and increased urine specific gravity. Monitor glucose for increase due to physiological stress. Insure timeliness of KUBs (most likely serial at this point). Insure family is updated on all aspects of disease and potential interventions to decrease worry and anxiety Same as Stage IA & IIA Stage IIB Moderately Ill (Early Definitive NEC) Radiological confirmation Same as IIA plus Mild metabolic acidosis, thrombocytopenia Definite tenderness Possible abdominal cellulitis, RLQ mass Radiological signs: Same as Stage IIA plus portal venous gas, possible ascites. Same as Stage IA & B and IIA & B plus: Septic shock Respiratory and metabolic acidosis Severe apnea and bradycardia Abdominal wall erythema Generalized peritonitis Radiological signs: Free intraperitoneal air Same as Stage IA & B and IIA. Stage IIIA (Advanced NEC: severely ill, bowel intact) Intubation if required for apnea and bradycardia Surgical intervention: Peritoneal drain, laparotomy with stoma, or primary anastomosis. Medical interventions: Same as earlier stages plus inotrope therapy for hypotension, blood product administration for DIC and anemia, and electrolyte replacement. Same as Stage IA plus: Manage inotrope therapy to avoid wide swings in blood pressure. Maintain patency of endotracheal tube to maximize bowel oxygenation Further minimize environmental stimuli. Continue to educate parents on disease process, reasons for reducing touch, and cues of pain and over-stimulation. (continued) 380 JOGNN Volume 36, Number 4

5 TABLE 1 (CONTINUED) Bell s Stages of NEC Severity and Focused Nursing Interventions Stage Signs and Symptoms Treatment Nursing Interventions Post Surgical Nursing Interventions if indicated: Monitor output from drains or ostomy. Use ostomy bag if needed to protect skin. Observe for changes in color of stoma and abdomen around stoma or peritoneal drain. Promptly administer blood products as ordered. Stage IIIB (Advanced NEC: severely ill, bowel perforated) Same as Stages IA & B, IIA & B and IIIA Bowel perforation Radiological sign: pneumoperitoneum (Based on Coit, 1999; McElhinney et al., 2000; Neu, 2005; Ward & Beachy, 2003 ). strictures. This procedure also does not allow for distal bowel rest and puts the infant at higher risk for subsequent bowel problems, including additional episodes of NEC. Same as Stages IA&B, IIA & B and IIIA Same as Stages IA, IIA and IIIA plus: Provide increased chaplain and social worker support to parents as indicated. Surgical Treatment Outcomes The levels of risk of the different surgical procedures (i.e. peritoneal drain insertion vs. laparotomy) are subject to controversy. However, the risk of mortality from peritoneal drain insertions has not been shown to be significantly different than laparotomy ( Moss et al., 2006 ). Outcomes of surgical treatment of NEC are dependent on the extent of damage due to NEC and the amount of bowel removed. Because NEC can affect segments of both large and small bowel, surgical resections that require removal of large portions of the bowel can lead to the development of short gut syndrome. Treatment outcomes also depend on the gestational age of the infant. Infants of earlier gestational age who require surgery due to perforated NEC have an increased risk of mortality ( Sharma et al., 2006 ). This risk increase might be due to co-morbidities of prematurity, such as intraventricular hemorrhage (IVH) and hyaline membrane disease (RDS) that can contribute to a less than favorable outcome ( Erlich, Sato, Short, & Hartman, 2001; Sharma et al., 2006 ). Surgical treatment of NEC can lead to growth impairments, as evidenced by smaller head circumferences, lower mean weight and height when compared to infants who did not experience NEC during hospitalization ( Salhab, Perlman, Silver, & Broyles, 2004 ). These growth impairments may be a result of continual nutritional deficits caused by inability of the infant to absorb nutrients due to short bowel syndrome. These deficiencies have been shown to persist up to age 22 months in former ELBW infants (Salhab et al., 2004). Traditionally, infants who are treated for NEC either medically or surgically have extended periods of NPO for bowel rest and receive hyperalimentation and lipids parenterally for nutritional support. Although total parenteral nutrition (TPN) has been a lifesaving therapy, this therapy puts the preterm infant at higher risk for catheter-related sepsis, cholestasis, and electrolyte disturbances, all of which have been linked to growth delays and later neurodevelopmental delays (Duran, 2005 ). Many investigators have examined the role of feeding in the prevention of NEC, but few have examined how feeding after treatment for NEC affects the infant s physical and neurodevelopmental outcomes. One team studied the effect of enteral feedings after NEC, but the sample was too small to produce generalizable results ( Bohnhorst et al., 2003 ). Later Neurodevelopmental and Growth Outcomes NEC has been associated with delayed growth and neurodevelopmental delays. Psychomotor and developmental outcomes associated with NEC are most often measured with the Bayley Scales, a standardized development assessment tool for infants from birth to 42 months of age. While there have been few studies of the relationship July/August 2007 JOGNN 381

6 between NEC and poor neurodevelopmental outcomes, findings indicate that this relationship exists. Poor outcomes are more common in infants who have experienced surgically treated NEC. Developmental index scores. Bayley scores of less than 70 on the MDI (Mental Development Index) are often indicative of severe neurologic or neurodevelopmental impairment, and scores less than 70 on the PDI (Psychomotor Development Index) are associated with poor psychomotor development. Surgically treated NEC was found to be an independent risk factor for scores below 70 on the MDI and PDI for extremely low birth weight (ELBW) infants when compared to those with no NEC. The same infants were found to have more cerebral palsy, deafness and blindness than infants with medical NEC or infants who had not experienced NEC ( Hintz et al., 2005 ). Similarly, when infants with NEC and spontaneous bowel perforation not related to NEC were compared, the infants with NEC were more likely to have MDI and PDI scores <70, providing increasing evidence that NEC is an independent risk fac tor for lower Bayley scores ( Adesanya et al., 2005 ). The combination of infection and NEC has also been linked to lower MDI and PDI scores and to an increased risk of cerebral palsy and vision, hearing, and neurodevelop mental impairments in ELBW infants at months when compared to infants who were uninfected ( Stoll et al., 2004 ). Growth. While some studies have shown that weight gain rates were slower in ELBW infants who had laparotomy for NEC ( Chacko, Ford & Haslam, 1999 ), others have shown that weight gain during hospitalization and at discharge was comparable for all ELBW infants, with equal proportions diagnosed with failure-to-thrive at 18 to 22 months of age ( Salhab et al., 2004 ). Despite this controversy, NEC has been identified as a contributing factor for failure-to-thrive in this population ( Salhab et al., 2004 ). Although weight gain outcomes may vary, short stature has been shown to be more universal in infants who have experienced medical and surgical NEC than in those who did not experience NEC ( Chacko, Ford & Haslam, 1999; Salhab et al., 2004 ). It is difficult to determine whether these differences in infant outcomes occurred solely because of the exposure to NEC or as a result of complications associated with surgical treatment of NEC. Growth impairment may be related to surgically induced short gut syndrome. Infants may also have post-surgical complications such as acidosis, hypotension and sepsis that require aggressive support ( Chacko, Ford & Haslam, 1999 ). Wound infections and strictures may occur. ELBW infants also face complications of extreme prematurity, such as RDS and intraventricular hemorrhage. It is difficult to determine whether or not NEC contributed to these comorbidities as a result of increased ventilator time and greater need for therapies for hypotension or sepsis. Preterm infants with necrotizing enterocolitis had lower MDI and PDI scores and higher rates of cerebral palsy, vision, hearing and neurodevelopmental impairment. Head circumference. Neurodevelopmental impairments are often accompanied by growth impairments, including poor growth in head circumference ( Hintz et al., 2005 ). Infants with surgically treated NEC had smaller head circumferences than infants with medically treated NEC or infants who had not experienced NEC ( Hintz et al., 2005 ). Infants with NEC were more likely to have head circumference measurements in the <5 th (Salhab et al., 2004) and <10 th ( Stoll et al., 2004 ) percentiles, which are consistent with abnormal neurodevelopmental outcomes. Infants treated for NEC who had small head circumferences also were more likely to have generalized hypotonia, spastic quadriplegia, spastic diplegia and spastic hemiplegia than those who did not experience NEC ( Salhab et al., 2004 ). Nursing Care Interventions The best possibility for preventing the growth and neurodevelopmental delays associated with NEC is to identify NEC in its earliest stage and prevent progression of the disease. Bedside nurses are the first line of defense in this effort, in that they are best able to detect early changes in the infant s gastrointestinal system ( Coit, 1999 ). In order to do this, nurses need to understand and be able to identify the early signs and symptoms of NEC as listed in Table 1. Preventive measures are essential. First and foremost, good handwashing must be performed, as most nosocomial infections are thought to be transmitted by the hands of health care workers ( Karabey, Ay, Derbentli, Nakipoglu & Esen, 2002 ). This may require nurses to police all those who have contact with the preterm infant to ensure that proper handwashing techniques are performed. While many interventions are multidisciplinary, nurses can pay particular attention to preterm infants who experience perinatal and neonatal events involving compromised oxygenation and/or blood flow. These NEC risk factors include abruptio placentae, low Apgar scores, apnea, and bradycardia (Luig, Lui & NSW/ACT NICUS Group, 2005 ). Frequent and thorough head-to-toe assessments are an essential part to the successful detection and management 382 JOGNN Volume 36, Number 4

7 of NEC. The nurse must pay particular attention to the gastrointestinal system and the infant s feeding tolerance, as changes associated with NEC may initially be quite minuscule. Small changes in the abdomen (color, increase in girth, changes in firmness or tenderness) should be reported immediately for further evaluation by a physician or neonatal nurse practitioner. The nurse caring for an infant at risk for necrotizing enterocolitis observes for minute changes in the infant s behavior, physiologic changes, or an alteration in overall presentation. The nurse caring for an infant at risk for NEC is a detective, observing for minute changes in the infant s behavior, such as apnea and bradycardia or lethargy, as well as physiologic changes such as decreased perfusion or temperature instability, or an alteration in the infant s overall presentation ( Coit, 1999 ). Nurses may develop an intuition or hunch of a decline in health status and should report when the infant is just not acting right or looks different. Subtle changes in the infant s appearance, activity level, and assessment parameters also can be signs of generalized sepsis ( Horton, 2005 ). Once the diagnosis of NEC is made, nurses can facilitate the recovery process by implementing developmentally supportive strategies that decrease the level of stress experienced by the infant. Clustering of care activities, designated periods of rest, removal of noxious environmental stimuli, and careful handling decrease stress and facilitate healing. Nurses must be proactive in the use of pain scores to identify pain treatment needs in infants undergoing medical and surgical interventions for NEC ( Coit, 1999 ). Hemodynamic stability is important in minimizing the devastating effects of NEC on the neurological system. Minimizing wide swings in blood pressure and providing developmentally appropriate care decrease the likelihood of intraventricular hemorrhage. If inotrope therapy is required, it should be delivered without interruptions that cause drops in blood pressure. If the infant is intubated, suction the endotracheal tube only as needed to maintain patency. Suctioning an unstable infant can contribute to episodes of oxygen desaturation, shifts in blood pressure, and increases in pain scores. While monitoring and managing the infant s bedside care, the nurse should make certain that the parents are frequently updated on the infant s medical condition. The chaplain and social worker should be made available to the family for spiritual, psychological and financial support. Conclusion Given the many comorbidities of prematurity, determining how medical and surgical treatments of NEC in preterm infants contribute to long term outcomes remains a challenge. Nevertheless, prevention and proper management of NEC by health care providers remains the most prudent method of decreasing the incidence and unfavorable outcomes of NEC. Close monitoring by nurses and prompt application of nursing interventions can have a profound effect on outcomes by minimizing internal and external causes of preterm infants instability and acting before NEC progresses to a more serious level. Nurses are in the forefront of effective prevention and treatment of NEC. Their interventions contribute to the stability of the infant s medical condition and decrease the risk of poor neurodevelopmental outcomes. Acknowledgments The author thanks Diane Holditch-Davis for her mentorship, support and guidance. REFERENCES Adesanya, O., O Shea, T. M., Turner, C. S., Amoroso, R. M., Morgan, T. M., & Aschner, J. L. ( 2005 ). Intestinal perforation in very low birth weight infants: Growth and neurodevelopment at 1 year of age. Journal of Perinatology, 25, Ahmed, T., Ein, S., & Moore, A. ( 1998 ). The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: Recommendations from recent experience. Journal of Pediatric Surgery, 33 ( 10 ), Bohnhorst, B., Muller, S., Dordlemann, M., Peter, C. S., Peterson, C., & Poets, C. F. ( 2003 ). Early feeding after necrotizing enterocolitis in preterm infants. Journal of Pediatrics, 143 ( 4 ), Caplan, M. S. & Jilling T. ( 2001 ). New concepts in necrotizing enterocolitis. Pediatrics, 13, Cass, D. L., Brandt, M. L., Patel, D. L., Nuchtern, J. G., Minifee, P. K., & Wesson, D. E. ( 2000 ). Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. Journal of Pediatric Surgery, 35 ( 11 ), Chacko, J., Ford, W. D., & Haslam, R. ( 1999 ). Growth and neurodevelopmental outcome in extremely-low-birthweight infants after laparotomy. Pediatric Surgery International, 15, Coit, A. K. ( 1999 ). Necrotizing enterocolitis. Journal of Perinatal and Neonatal Nursing, 12 ( 4 ), Diehl-Jones, B., & Askin, D. F. ( 2004 ). Nutritional modulation of neonatal outcomes. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 15 ( 1 ), July/August 2007 JOGNN 383

8 Duran, B. ( 2005 ). The effects of long-term total parenteral nutrition of gut mucosal immunity in children with short bowel syndrome: A systematic review. BMC Nursing, 4, 2. Dzakovic, A., Notrica, D. M., Smith, E. O., Wesson, D. E., & Jaksic, T. ( 2001 ). Primary peritoneal drainage for increasing ventilatory requirements in critically ill neonates with necrotizing enterocolitis. Journal of Pediatric Surgery, 36 ( 5 ), Erlich, P. F., Sato, T. T., Short, B. L., & Hartman, G. E. ( 2001 ). Outcome of perforated necrotizing enterocolitis in the very low-birth weight neonate may be independent of type of surgical treatment. The American Surgeon, 67, Henry, M. C. & Moss, R. L. ( 2004 ). Current issues in the management of necrotizing enterocolitis. Seminars in Perinatology, 28 ( 3 ), Hintz, S. R., Kendrick, D. E., Stoll, B. J., Vohr, B. R., Fanaroff, A. A., Donovan, E. F., et al. ( 2005 ). 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Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. The New England Journal of Medicine, 354 ( 21 ), Neu, J. ( 2005 ). Neonatal necrotizing entercolitis: An update. Acta Paediatrica, 94, Salhab, W. A., Perlman, J. M., Silver, L., & Broyles, R. S. ( 2004 ). Necrotizing enterocolitis and neurodevelopmental outcome in extremely low birth weight infants <1000 g. Journal of Perinatology, 24, Sharma, R., Hudak, M. L., Tepas III, J. J., Wludyka, P. S., Marvin, W. J., Bradshaw, J. A., et al. (2006 ). Impact of gestational age on the clinical presentation and surgical outcome of necrotizing enterocolitis. Journal of Perinatology, 26, Stoll, B. J., Hansen, M. I., Adams-Chapman, I., Fanaroff, A. A., Hintz, S. R., Vohr, B., et al. (2004 ). Neurodevelopmental and growth impairment among extremely low-birthweight infants with neonatal infection. JAMA, 292 ( 19 ), Vohr, B. R., Wright, L. L., Dusick, A. M., Mele, L., Verter, J., Steichen, J. J., et al. (2000 ). Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, Pediatrics, 105 ( 6 ), Ward, R. M & Beachy, J. C. ( 2003 ). Neonatal complications following preterm birth. BJOG, 110, Address for correspondence: Brigit M. Carter, RN, MSN, CCRN, School of Nursing, University of North Carolina at Chapel Hill, UNC-Chapel Hill Carrington Hall, CB #7460 Chapel Hill, NC bmcarter@ .unc.edu. Continuing Nursing Education (CNE) Credit To take the test and complete the evaluation, please visit Certificates of completion will be issued on receipt of the completed evaluation form, application and processing fees. Note: AWHONN contact hour credit does not imply approval or endorsement of any product or program. Objectives After reading this article, the learner will be able to: 1. Describe the impact of necrotizing enterocolitis on neurodevelopmental outcomes of premature infants. 2. Distinguish the differences in treatment and neurodevelopmental outcomes of infants with medical versus surgical NEC. 3. Identify nursing interventions that will reduce the risk of poor neurodevelopmental outcomes in premature infants who experience medical or surgical NEC. 384 JOGNN Volume 36, Number 4

9 Post-Test Questions Instructions : To receive contact hours for this learning activity, please complete the online post-test and evaluation at CNE for this activity is available online only ; written tests submitted to AWHONN will not be accepted. 1. Medical treatment of necrotizing enterocolitis a. increases the risk of short gut syndrome b. includes progressive oral feedings c. requires serial X-rays to monitor pneumatosis 2. Nurses can reduce risk and severity of NEC by a. encouraging frequent enteral feedings b. frequent and prolonged suctioning of endotracheal tubes c. monitoring bowel sounds and reporting decreases. 3. Although survival after NEC has improved, the incidence of NEC has not diminished because a. knowledge of pathophysiology of the disease has not advanced b. more extremely and very low birthweight infants are surviving c. there are insufficient advances made in the treatment of NEC 4. Perinatal and neonatal risk factors for NEC in the preterm infant include a. abruptio placentae b. hypoglycemia c. bradycardia 5. The pathogenesis of NEC involves a. bacterial infection b. fungal infection c. parasitic infection 6. Surgical interventions are indicated when a. apnea and bradycardia are present b. the abdomen distends c. the bowel has perforated 7. A symptom of short gut syndrome is a. hypervolemia b. malabsorption c. mechanical obstruction 8. Bowel resections with ostomy formation pose this additional threat to the infant: a. leakage of bowel contents is more common than after primary anastomosis b. failure to allow for distal bowel rest which can cause reoccurrence of NEC c. requires repeat surgery for reanastomosis which increases exposure to risk 9. The risk of mortality from peritoneal drain insertions been shown to be a. greater than laparotomy b. less than laparotomy c. not significantly different than laparotomy 10. NEC affects a. both the large and small bowel b. the large bowel only c. the small bowel only 11. Treatment with hyperalimentation increases an infant s risk of a. cholestasis b. esophagitis c. hypothermia 12. Later growth impairments more common in children with surgically treated NEC include a. enlarged abdomen b. macrocephaly c. short stature 13. In infants with medical or surgical NEC, a strong link to poor neurodevelopmental outcomes is a. Bayley PDI score <70 b. short stature c. slow weight gain 14. Developmental practices that reduce stressors and improve neurodevelopmental outcomes include a. changing the infant s position frequently b. encouraging rest periods through clustered care c. spreading out care so each contact is short 15. Suctioning an unstable infant can contribute to a. hypovolemia b. shifts in blood pressure c. spikes in temperature July/August 2007 JOGNN 385