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NECROTIZING ENTEROCOLITIS

As if the birth of a premature baby isn't stressful enough, premature babies can experience a number of diseases within the first weeks of life. Necrotizing enterocolitis (NEC) is one of them. "Necrotizing" means the death of tissue, "entero" refers to the small intestine, "colo" to the large intestine, and "itis" means inflammation. But knowing what the words mean is only the start of understanding this infant disease. A gastrointestinal disease that mostly affects premature infants, NEC involves infection and inflammation that causes destruction of the bowel (intestine) or part of the bowel. Although it affects only 1 in 2,000 to 4,000 births, or between 1% and 5% of neonatal intensive care unit (NICU) admissions, NEC is the most common and serious gastrointestinal disorder among hospitalized preterm infants. NEC usually occurs within the first 2 weeks of life, usually after milk feeding has begun (at first, feedings are usually given through a tube that goes directly to the baby's stomach). About 10% of babies weighing less than 3 lbs.5 oz. (1,500 grams) experience NEC. These premature infants have immature bowels, which are sensitive to changes in blood flow and prone to infection. They may have difficulty with blood and oxygen circulation and digestion, which increases their chances of developing NEC. Causes The exact cause of NEC is unknown, but one theory is that the intestinal tissues of premature

infants are weakened by too little oxygen or blood flow. So when feedings are started, the added stress of food moving through the intestine allows bacteria normally found in the intestine to invade and damage the wall of the intestinal tissues. The damage may affect only a short segment of the intestine or can progress quickly to involve a much larger portion. The infant is unable to continue feedings and starts to appear ill if bacteria continue to spread through the wall of the intestines and sometimes into the bloodstream. He or she may also develop imbalances in the minerals in the blood. In severe cases of NEC, a hole (perforation) may develop in the intestine, allowing bacteria to leak into the abdomen and cause lifethreatening infection (peritonitis). Because the infant's body systems are immature, even with quick treatment for NEC there may be serious complications. Other factors seem to increase the risk of developing NEC. Some experts believe that the makeup of infant formula, the rate of delivery of the formula, or the immaturity of the mucous membranes in the intestines can cause NEC. (Babies who are fed breast milk can also develop NEC, but their risk is lower.) Another theory is that babies born through difficult deliveries with lowered oxygen levels can develop NEC. When there isn't enough oxygen, the body sends the available oxygen and blood to vital organs instead of the gastrointestinal tract, and NEC can result.
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Babies with an increased number of red blood cells (polycythemia) in circulation also seem to be at higher risk for NEC. Too many red blood cells thicken the blood and hinder the transport of oxygen to the intestines. NEC sometimes seems to occur in "epidemics," affecting several infants in the same nursery. Although this may be due to coincidence, it suggests the possibility that it could in some cases be spread from one baby to another, despite the fact that all nurseries have very strict precautions to prevent the spread of infection. Signs and Symptoms The symptoms of NEC can resemble those of other digestive conditions, and may vary from infant to infant. Common symptoms include: poor tolerance to feedings feedings stay in stomach longer than expected decreased bowel sounds abdominal distension (bloating) and tenderness greenish (bile-colored) vomit redness of the abdomen increase in stools, or lack of stools bloody stools

Diagnosis and Treatment The diagnosis of NEC is usually confirmed by the presence of an abnormal gas pattern as seen on an X-ray. This is indicated by a "bubbly" appearance of gas in the walls of the intestine, large veins of the liver, or the presence of air outside of the intestines in the abdominal cavity. A surgeon may insert a needle into the abdominal cavity to withdraw fluid to determine whether there is a hole in the intestines. Most infants with NEC are treated medically, and symptoms end without the need for surgery. Treatment includes: stopping feedings nasogastric drainage (inserting a tube through the nasal passages down to the stomach to remove air and fluid from the stomach and intestine) intravenous (IV) fluids for fluid replacement and nutrition antibiotics for infection frequent examinations and X-rays of the abdomen

More subtle signs of NEC might include apnea (periodic stoppage of breathing), bradycardia (slowed heart rate), diarrhea, lethargy, and fluctuating body temperature. Advanced cases may show fluid in the peritoneal (abdominal) cavity, peritonitis (infection of the membrane lining the abdomen), or shock.

The baby's belly size is measured and watched carefully, and periodic blood samples are taken to look for bacteria. Stools are also checked for blood. If the abdomen is so swollen that it interferes with breathing, extra oxygen or mechanically assisted breathing (a ventilator) is used to help the baby breathe. A baby who responds favorably may be back on regular feedings within 72 hours, although in most cases feedings are withheld and antibiotics are continued for 7 to 10 days. If the bowel perforates (tears) or the condition worsens, surgery may be indicated.
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Severe cases of NEC may require removal of a segment of intestine. Sometimes after removal of diseased bowel, the healthy areas can be sewn back together. Other times, especially if the baby is very ill or there is spillage of stool in the abdomen, the surgeon will bring an area of the intestine or bowel to an opening on the abdomen (called an ostomy). Most infants who develop NEC recover fully and do not have further feeding problems. In some cases, scarring and narrowing of the bowel may occur and can cause future intestinal obstruction or blockage. Another residual problem may be malabsorption (the inability of the bowel to absorb nutrients normally). This is more common in children who required surgery for NEC and had part of their intestine removed. Caring for Your Child NEC can be extremely frightening to parents. Parents who are deprived of the experience of feeding their babies will certainly feel frustrated their infant is so small, it just doesn't feel right to stop feedings. As important as it is to be able to hold and bond with your baby, this may not be possible while the baby is in critical condition. Listen to and take comfort from the NICU staff they are trained and eager to support parents of preemies as well as the preemies themselves. Remember that there's a good chance that your baby will be back on regular feedings within a short time.

INTRAVENTRICULAR HEMORRHAGE IVH


An intraventricular hemorrhage, also called IVH, is bleeding into theventricles of the brain. An IVH can be mild or severe, depending on how much bleeding there is. Some babies won't have any long term effects, while babies with more extensive bleeds might have developmental delays or other lasting effects. Severity of Intraventricular Hemorrhages (IVH) In infants, intraventricular hemorrhages are labeled by how severe the hemorrhage is.

Grade 1: Bleeding is limited to the

germinal matrix, a fragile area near the ventricles that contains many small capillaries. Grade 1 IVH is also called germinal matrix hemorrhage.

Grade 2: Bleeding is found in the

ventricles, but the ventricles remain the same size.

Grade 3: Bleeding is found in the

ventricles, and the bleeding has caused the ventricles to dilate, or grow larger.

Grade 4: Blood is found in the

ventricles, which have dilated, and in nearby areas of the brain. Grade 4 IVH is also called intracranial hemorrhage. Grade 1 and 2 hemorrhages are usually considered mild bleeds, while grade 3 and 4 bleeds are more severe, with more serious initial symptoms and more long-term complications.

What Causes IVH? Prematurity is the greatest cause of intraventricular hemorrhage, and most cases of IVH occur in babies less than 30 weeks gestation or under 1,500 grams (3 lbs 5 oz). Intraventricular hemorrhages happen early in a preemies life, with 90% occurring within the first 3 days of life. Doctors think that several things combine to make preemies susceptible to IVH. First, the blood vessels in a preemies brain are more fragile than those in a term baby. Premature babies also may suffer from repeated episodes of low blood-oxygen levels, and are exposed to greater fluctuations in blood pressure. What Are the Symptoms of IVH? Babies suffering from mild hemorrhages may not have any symptoms. Symptoms of more severe intraventricular hemorrhages in premature babies include:

How Is IVH Treated? Unfortunately, there is no way to stop an intraventricular hemorrhage once it has begun. Treatment for IVH targets symptoms of the bleed, and may include increased respiratory support or medications for apnea and bradycardia. Up to 10% of infants who have an intraventricular hemorrhage will develop hydrocephalus, a buildup of cerebrospinal fluid in the ventricles. Hydrocephalus makes an infants head grow more quickly than usual to make room for the extra fluid, and can put pressure on delicate brain tissue. Hydrocephalus may go away on its own, or surgery may be required. Doctors may decide to insert a ventriculoperitoneal shunt (VP shunt) to drain the fluid and reduce pressure on the brain. What Are the Long-Term Consequences of IVH? Long-term consequences may be mild or severe, and are usually related to the severity of the hemorrhage. Infants who have grade 1 or 2 bleeds may have no lasting effects, or may have subtle consequences that are difficult to measure. All children who suffered from IVH as infants are more likely to use special education services than children who did not suffer from IVH. Many children with serious hemorrhages will have no lasting effects, but children who suffer from grade 3 and 4 hemorrhages as infants are at risk for more serious consequences.Developmental delays may be severe as these babies grow. Children with a history of severe bleeds may also suffer from
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Increased episodes of apnea and Decreased muscle tone Decreased reflexes Weak suck Excessive sleep

bradycardia

How Is IVH Diagnosed? Intraventricular hemorrhages are diagnosed with an ultrasound of the head. Many hospitals routinely screen all premature babies for IVH within the first week of life and again before hospital discharge.

poor cognitive functioning and other disorders such as attention deficit-hyperactivity disorder (ADHD). Preventing IVH Because IVH causes such severe complications and cannot be stopped once it has begun, doctors and scientists have focused their efforts on prevention. Preventing preterm delivery is the best way to prevent IVH, so expectant mothers with risks for preterm delivery should talk to their doctors about lowering their risk. Several medications have been studied for their role in preventing IVH. Antenatal steroids in women who are at risk for an early delivery have been shown to give some protection, but must be given in a narrow time window. Another medication, indomethicin, has also been shown to give some protection.

certain strains of streptococcus, may cause neonatal sepsis. Early-onset neonatal sepsis most often appears within 24 hours of birth. The baby gets the infection from the mother before or during delivery. The following increases an infant's risk of early-onset sepsis: Group B streptococcus (group b strep) infection during pregnancy Preterm delivery Rupture of membranes (placenta tissue) that lasts longer than 24 hours Infection of the placenta tissues and amniotic fluid (chorioamnionitis)

Babies with late-onset neonatal sepsis get infected after delivery. The following increase an infant's risk of sepsis after delivery: Having a catheter in a blood vessel for a long time Staying in the hospital for an extended period of time

NEONATAL SEPSIS
Definition Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Early-onset sepsis is seen in the first week of life. Late-onset sepsis occurs between days 8 and 89. Alternative Names Sepsis neonatorum; Neonatal septicemia; Sepsis - infant Causes A number of different bacteria, including Escherichia coli (E.coli), Listeria, and

Symptoms Infants with neonatal sepsis may have the following symptoms: Body temperature changes Breathing problems Diarrhea Low blood sugar Reduced movements Reduced sucking Seizures Slow heart rate Swollen belly area Vomiting Yellow skin and whites of the eyes (jaundice)

Exams and Tests

Laboratory tests can help diagnose neonatal sepsis and identify the bacteria that is causing the infection. Blood tests may include:

Babies who do require treatment will be admitted to the hospital for monitoring. Outlook (Prognosis)

Blood culture C-reactive protein Complete blood count (CBC)

A lumbar puncture (spinal tap) will be done to examine the cerebrospinal fluid for bacteria. If the baby has a cough or problems breathing, a chest x-ray will be taken. Urine culture tests are done in babies older than several days. Treatment Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results are back. (Lab results may take 2472 hours.) This practice has saved many lives. Older babies may not be given antibiotics if all lab results are within normal limits. Instead, the child may be followed closely on an outpatient basis.

With prompt treatment, many babies with these bacterial infections will recover completely with no remaining problems. Nevertheless, neonatal sepsis is a leading cause of infant death. The more quickly an infant receives treatment, the better the outcome. Possible Complications

Disability Death

Prevention Preventative antibiotics may be given to pregnant women who have a Group B Streptococcusinfection or who have previously given birth to an infant with sepsis due to the bacteria. Preventing and treating infections in mothers, providing a clean birth environment, and delivering the baby within 24 hours of rupture of membranes, where possible, can all help lower the chance of neonatal sepsis.

REPORTED BY: CYD MENDOZA, RN SHEILA JANE RONAN, RN TEHREENA JOY CONSTANTE, RN

Remember that there are three main blood types, including types A, B, and O. Since babies inherit

ABO INCOMPATIBILITY
Q. When my daughter was born she had severe jaundice and they told me that it was due to an ABO Incompatibility. I am type O+ and she is type A. She was given two transfusions of a type that did not stop her immune breakdown. Then they gave her a type O transfusion. Is it possible for a mother with type O blood to have an Incompatibility with a child of blood type A? And if we were incompatible, why did they give her a type O transfusion?

their blood type from each parent, it is possible for a mother and baby to have different blood types. For example, a mother who is type O and a father who is type A could have a baby who is type A.

With an ABO incompatibility, a mother makes antibodies against her baby's blood type. It doesn't happen if the mother and baby have the same blood type or if the baby is type O, since in that case, there is usually nothing to make antibodies against.

These antibodies, if the mother is type O, can My father in law is telling me that it is impossible to have an incompatibility between these two, and all I went through was for nothing. When the doctor in charge of the NICU explained what he did, he said something about that when they gave her the type A transfusion it was like feeding her my blood and more molecules break down more. When they gave her type O, I was concerned because of the ABO incompatibility. My doctor said she can have type O and that there was nothing more for the blood to fight. Is that true? Please can you explain this to me in a way I can understand. Tanya, Bellingham, WA Although many children with an ABO A. It would only be impossible to have a reaction like this if you were type A and the baby was type O. incompatibility do not need any treatment at all, some do require extensive phototherapy if the baby is very jaundiced. This is usually continued until the mother's antibodies are cleared from the If a mother is type A or B and the baby has a different blood type other than type O, she can still make antibodies against the baby's red blood cells. These antibodies are too large to cross the placenta though, and so don't usually lead to any problems. cross the placenta and can break down the baby's red blood cells after she is born, leading to jaundice and anemia. This condition is called Hemolytic Disease of the Newborn or erythroblastosis fetalis, and it can also be caused by having an Rh incompatibility between a baby and mother.

baby's body, which happens on its own after a few days.

If she really got a type O transfusion later on, I guess that it could be possible that they just didn't have any type A blood available to give her. Keep

An ABO incompatibility that leads to jaundice, anemia, and the need for transfusions can definitely happen if the mother is type O and the baby is either type A or B.

in mind that type O- blood is the 'universal donor' type of blood, because it can be given to people who are type A, B, or O.

If you still aren't sure what happened to your Why did she get two different types of blood transfusions? The first two were likely exchange transfusions, in which much of the baby's blood is removed and type O blood is given back. If they simply gave the baby more type A blood at that time, your antibodies would have just broken it down more. daughter, it would likely be best to call the NICU and have the NICU attending explain things to you again. You could also ask your Pediatrician to request the records from the NICU and review them for you.

So I think that you may have the types of transfusions that she got backwards. Are you sure that they gave her the type A transfusion first and then later gave a type O transfusion?

Keep in mind that an exchange transfusion is much different than a traditional transfusion, where you are simply given extra blood.

Why did she then get another transfusion? The last transfusion was likely a regular transfusion with type A blood that matched her own blood type. This would usually be needed if she got so anemic from the ABO incompatibility that she needed extra blood. By this time, your antibodies were likely out of her system, so there was no worry that she would break down this transfused blood.

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