1 Ashley Robson 2212 Canyon Creek Dr. Mckinney, TX 75070 September 2 nd 2014 Debra Brandon PhD, RN, CCNS, FAAN Duke University School of Nursing Durham, NC Dear Mrs. Brandon- I would like the opportunity to submit a manuscript to Advances in Neonatal Care. The manuscript will be a review of the use of probiotics for the prevention of Necrotizing Entercolitis in the neonate. It has been studied that prevention of Necrotizing Entercolitis can possibly be accomplished by the use of prophylactic enteral probitoics. This has thought to play a role in reducing the morbidity and mortality associated with NEC. This manuscript will include study related information on the prevention of NEC in the preterm infant. Also, the economic, emotional and social impact will be discussed. The evidence-based practice around the use of probiotics will be discussed. I have over eight years of nursing experience, caring for the neonate and families. I began my career as an intern in the Newborn Nursery and upon graduation from nursing school completed my residency nursing program in a Neonatal Intensive Care Unit. I am currently completing my Master of Science in Nursing in pursuit of becoming a neonatal nurse practitioner and will graduate in December 2014, I can have the manuscript completed by November 20, 2014, or sooner if that better
2 meets your publication needs. Please email me at asrobson@utmb.edu with any questions. Thank you for your consideration. Sincerely, Ashley Robson, BSN, RNC-NIC
3 Title Page: Manuscript of the use of Probiotics in the Prevention of Necrotizing Entercolitis in Neonates Author: Ashley Robson, BSN, RNC-NIC Address: 2212 Canyon Creek Dr. McKinney, TX 75070
4 Abstract: The use of probiotics in the neonatal population might prevent the development of Necrotizing Entercolitis. The problem statement is: Could the use of probiotics prevent the development of Necrotizing Entercolitis? The approach of this practice change is to provide as much research as possible to make an accurate decision on the use of probiotics. The result is that there is still further research that needs to be conducted to come up with an outcome. The development of Necrotizing Entercolitis is detrimental to the infant, families, and hospital and having an simple intervention that could prevent that warrants further investigation The following manuscript has never been published and is not currently under consideration by another company. Also, there weren t any conflicts of interest identified in this manuscript.
5 Introduction Necrotizing Entercolitis (NEC) is an acute inflammatory disease with multiple factors and controversial etiology. Research has proposed NEC to be caused from a reperfusion injury that activates an inflammatory cascade reaction; partial or full-thickness necrosis then occurs leading to perforation of the intestinal tract (Springer, 2014). NEC occurs in about ten percent of neonates weighing less than 1500 grams, and mortality occurs in fifty percent of those infants (Springer, 2014). NEC is the most common medical and surgical emergency in neonates (Springer, 2014). Although studies have not identified a definite cause of NEC, there are several proposed pathologies. Maternal Pathophysiology Maternal factors identified as correlating to NEC cases include: drug use, hypertension, infection, and any problem that leads to decreased placental blood flow (Gephart, McGrath, Effken, & Halpern, 2012). Correlation of cocaine use with NEC have been identified in previous studies, with infants of cocaine abusing mothers developing NEC at a higher percentage than those of mothers who did not use drugs (Gephart et al., 2012). Hypertensive mothers, both chronic and pregnancy-induced, have been found to have infant s with higher rates of developing NEC although the association of magnesium use for hypertension was not found as a risk factor. Maternal infections, such as human immunodeficiency
6 virus (HIV), have been found to have an increased risk of birthing infants who later develop NEC. Fetal Pathophysiology Although further research is needed in relating fetal pathophysiology to NEC, studies have found hypoxic-ischemic compromise and bacterial infections in utero to have a distinct correlation with developing NEC (Gephart et al., 2103). Hypoxic-ischemic compromise of: maternal cardiac arrest, umbilical cord prolapse, and placental abruption have been found to be intra-partum risk factors relating to NEC (Gephart et al., 2013). Bacterial colonization is also indicated as a causative factor due to the decreased number or complete absence of anaerobe bacteria in preterm infant s intestines. The lack of anaerobic bacteria causes a reduction in the anti-inflammatory effects and mucosal defense of probiotic organisms (Martin et al., 2011). Impact of the maternal condition on the fetus Maternal hypertensive disorders reduce blood flow from the placenta to the fetus causing a variable degree of hypoxia and intrauterine growth restriction. Intrauterine growth restriction is a finding in many research studies connecting hypertension and NEC (March, Gupta, Modest, Hacker, Martin, & Rana, 2014).
7 Intrauterine growth restriction is also a causative factor in low birth weight, which is a major correlating factor in NEC. Clinical manifestations and diagnostic evaluation of the neonate Preterm infants with low birth weights are at highest risk of developing NEC. Symptoms usually develop two to three weeks after birth, but have been seen as early as one to three days after birth (Springer, 2014). Clinical manifestations seen in patients with NEC are generally subtle signs of feeding intolerance that progress over several hours. Symptoms can include: tenderness to the abdomen, increased abdominal girth, vomiting, bloody stools, bloody gastric residuals, visible bowel loops, apnea, bradycardia, circulatory collapse, decreased perfusion to extremities, and temperature instability (Springer, 2014). Pnuematosis intestinalis upon abdominal x-ray is a classic sign of NEC. Usually there is some underlying disease including: anemia, asphyxia, cardiopulmonary disease, polycythemia, and abnormal bacterial colonization. Differential diagnoses of NEC include hypoplastic left heart syndrome, intestinal malrotation, volvulus, bacterial meningitis, sepsis, omphalitis, urinary tract infections, and prematurity. Therapeutic approaches and treatment options
8 The treatment varies based on symptoms and the degree of the disease process. Bowel rest should be provided by eliminating feeds from the infant s nutritional plan and providing nutrition with intravenous dextrose, amino acid, and electrolytes. Decompression of the stomach from low intermittent suction via a replogle tube will aid in bowel rest. A blood culture should be performed initially prior to antibiotic therapy to determine the presence of an infection, a complete blood count should be drawn and monitored throughout the course of illness to monitor white blood cell counts and hemoglobin and hematocrit. Serial abdominal x-rays should be obtained to monitor the intestines for perforation. Antibiotic therapy should begin after blood culture is drawn and should continue for 10-14 days. Ampicillin and gentamycin should be started and antibiotic therapy changes can be made based upon the blood culture results. If advanced NEC is present signs and symptoms of apnea, increased need of respiratory support, hypotension, decreased urine output, redness in the abdominal area, fluid or gas in the abdominal cavity, and lactic acid build up will be present. A surgical consult should be requested and exploratory surgery and removal of necrotic bowel should be performed. Pertinent theories and Evidence Based Practice Although research is limited in defining the causative factor or NEC, there are some methods to prevent NEC. Initiating trophic feedings soon after delivery
9 to prime the intestinal tract and using only expressed breast milk, which has mucosal protection, have been shown to reduce the risks of developing NEC. Antenatal steroids have mixed research outcomes on the benefits of reducing NEC, some suggest a reduction in the NEC cases by fifty percent and others suggest antenatal steroids increase the risk of NEC. Probiotics have been studied and show potential in reducing the incidence of NEC, but preparation is still undergoing studies (Springer, 2013). The presence of probiotics in the intestinal tract is important to protect the integrity of the mucosa. Probiotics improve the quality of the intestinal mucus, improve gut motility, and control the cytokine production (Springer, 2013). Probiotics will also compete against pathogenic bacteria to limit the overgrowth of pathogens in the intestines (Springer, 2013). There are many factors that can contribute to pathogenic bacterial colonization of the intestinal tract: type of delivery, amniotic fluid characteristics, diet, environmental exposure, and antibiotic use. With increasing factors of pathogenic bacteria colonization, the use of probiotics might prevent the prevalence of NEC by decreasing pathogenic bacteria. The four main types of organisms studied with the use of probiotics are: Strepococcus, Lactobacillus, Sacchormyces, and Bifodbacterium; streptococcus being a main infection causing bacteria in the preterm infant population. In the United States, the only probiotic is Good Start Natural Cultures with Bifidobacterium lactis for infants. (Ladd & Ngo, 2009).
10 Economic, emotional and social implications on the family unit When discussing the economic implication of the family unit when their child is faced with a devastating disease such as Necrotizing Entercolitis is profound. With this illness or any illness, families will have increased stress, have a difficult time concentrating at work, feel guilty, and have reduced self-esteem. All of these things could potentially have an effect on the parents as a unit. The amount of time the parents are at the hospital may cause areas in their life to be affected including: household tasks, family and community ties, and leave the family with a feeling of isolation. Resources need to be provided to all the families of infants in the Neonatal Intensive Care Unit including resources for economic, emotional, and social needs of the family unit. Conclusion In conclusion, past research has presented us with information to believe that probiotic use in the Neonatal Intensive Care Unit (NICU) could prevent the development of NEC. Further research still needs to be done in this area. The development of Necrotizing Entercolitis is detrimental to the infant, families, and hospital and having an simple intervention that could prevent that warrants further investigation.
11 References Springer, S.C., (2014). Necrotizing Enterocolitis. Retrieved from: http://emedicine.medscape.com/article/977956- overview. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2709096/ Fanaroff, A. A., & Martin, J. M. (2013). Klaus & Fanaroff s care of the high-risk neonate 6th ed. Philadelphia, PA: Saunders. Gephart, S. M., McGrath, J. M., Effken, J. A., & Halpern, M. D. (2013). Necrotizing enterocolitis risk. Advanced Neonatal Care. 12(2). 77-89. Ladd, N., Ngo, Tiffany. (2009). The use of probiotics in the prevention of necrotizing enterocolitis in preterm infants. Baylor University Medical Center Proceedings. 22(3): 287-297. March, M. I., Gupta, M., Modest, A. M., Hacker, M. R., & Rana, s. (2014). Maternal risk factors for neonatal necrotizing enterocolitis. Journal of Maternal Fetal Neonatal Medicine. 1-6.