Raising Awareness of Necrotizing Enterocolitis (NEC) Risk Factors With the eNEC Tools Christine Wetzel RNC-NIC, MSN, IBCLC contact: chris.wetzel@carle.com

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Clinical Problem Clinical Question

Within the largest NICU quality data base in the United States, data shows only

56% of VLBW infants are discharged still receiving their mother’s own milk. Would

mothers pump longer if they understood the individual risk of their own infant?

Nurses play a direct role in prevention of NEC by coaching the mothers of premature

infants to pump their breastmilk. NEC is a relative unknown disease which may impact

the mother’s perception of the dangers of NEC. Possibly leading her to believe the

disease is not a real threat to her baby and contribute to lack of commitment to

provider her breastmilk.

The eNEC tools were created from the evidence to raise awareness of individual

infant risk factors for feeding intolerance and NEC and could be used as an

education tool for parents.

Background.

Babies Need Their M.O.M.

The single most important intervention to prevent NEC is to provide the infant with their mothers

own milk (M.0.M.). Babies need their M.O.M. (Mother’s Own Milk)

So

We had a Bikini Party to Promote Breastfeeding and hung stars in the Milky Way

The strongest intervention shown to reduce NEC rates is to feed the infant their mother’s own milk

(MOM). Nursing practice can and does impact breastfeeding rates. Nurses can target interventions

to improve initiation and duration of mothers pumping their breastmilk.

- GI Symptoms

o Frank fresh blood in stool (hematochezia),

emesis or gastric aspirates

o Watery stool

o No stool for 24-36 hours

o Bilious emesis

o Bilious gastric aspirates

o 3rd emesis in 24° - if large or accompanies other

symptoms don’t wait for 3

o 3rd residual more than 50% in 24° (Carle

protocol)

o watch for trends of increasing residuals and

report trends – even trends of less than 50%

- ***Notify provider for these abnormal conditions***

Interventions

o Warm feedings

o Assess gastric aspirate prior to

each new feeding

o Verify gastric tube placement

o Consider osmolatity of feeding and

medications goal 450 mOsm/Kg

o Position left lateral, prone or in

kangaroo care during feeding and

30 min after feedings

o HOB 30°

o Support, educate and encourage

mother to pump her breastmilk –

mother’s own milk (MOM) is the

ONLY research based intervention

to prevent NEC

o Colostrum oral care – provides

colonization of good bacteria

o Follow milk prep/storage

guidelines to ensure infant food

safety

o Assess mother’s pumping & storing

practice

o Encourage bedside pumping

o Encourage skin to skin holding and

nonnutritive breastfeeding

o Advise mother to decrease or

eliminate dairy intake

Cardiopulmonary

Presentation

• Hypotension (this is a

late sign)

• Prolonged cap refill –

correlates to poor gut

perfusion

• Increased bradycardia

events

• Apnea

• Pale, mottled color

***Notify provider for

these abnormal

conditions***

o Interventions

o B/P Q6° - assess for hypotension

and a decrease in MAP from

baseline

o Assess cap refill Q6°

o Assess gavage tube placement –

can cause brady events when

displaced

o Reposition infant to ensure open

airway /ensure nasal cannula in

place- tubing not occluded

o Suction infant nares and mouth to

ensure infant has clear airway

- Clinical Change/Deterioration

o Oxygen desaturations and/or

increased oxygen requirement

o Temperature instability – (early

sign)

o Lethargy or irritability – early sign

o hyponatremia

o Decreased platelets /mild

thrombocytopenia (moderately ill)

o Metabolic Acidosis

o Neutropenia or Luekopenia with

increased bands

o Increased NPASS score

o Blood glucose instability

o Decreased urine output

o Increased CRP

*** Notify Provider for these abnormal

findings***

Interventions

o Strict I and O

o Hourly documentation of oxygen

requirements and pulse ox

o Document Q1-2° NPASS score and

pain interventions

o Watch for increasing heat

requirements – bed temp changes

o Review infant labs – notify

provider for abnormal lab values

- Abdominal Assessment: The 3 D’s distention, discoloration,

discomfort

o Increased Distention > 2cm

o Discoloration of abdomen,– bluish or red color

o Presence of bowel loops. Fixed Loops have higher

clinical NEC correlation

o Tenderness (mild illness)/discomfort (moderately

ill)/firmness (severely ill)

o Hypoactive or absent bowel sounds

o Abdominal firmness, taunt – late sign of NEC (may

look shiny)

***Notify provider for these abnormal findings***

Interventions

o Measure abdominal circumference Q6° if clinical signs are

changing

o Assess/palpate abdomen Q6° - report dark (lack of perfusion)

or red color (may be cellulitis)

o During RN handoffs, visualize loops together. Call if loops are

fixed

o Assess Pain – NPASS score Q 2-3 hours – report increased

pain

o Auscultate bowel sounds; all 4 quads

o Vent feeding tube between feeds for infants on CPAP or HFNC

o Aspirate gastric air prior to feedings

o Implement Nursing Standards for Assessment of Enteral

Feeding Tolerance In VLBW Infant

o Implement NEC Care Plans/standards per hospital protocol

o Gently shake milk prior to drawing up feeding and then again

before giving to infant - to disburse fortifier settlement

o Set feeding pump at vertical angle so infant gets composite

milk vs high lactose milk

Enec Tool: Assessment for Infant Risk Factors for NEC and Feeding IntoleranceInfant gestation at birth

1 point 32-36 6/7 weeks 2 points <32 weeks (very premature infant) 3 points <28 weeks (extreme premature infant)

Infant birth weight 0 points More than 2500 grams 1 point Low Birth Weight (LBW) <2500 grams 2 points Very Low Birth Weight (VLBW) <1500 g 3 points Extremely Low Birth Weight (ELBW) <1000 g

Feeding- choose highest point applicable If the baby is fed formula, fortifier or donor milk the highest point must remain the score

0 points – Mothers own milk 1 point Donor Milk (includes prolacta) 1 point NPO (this is the only point that can be reduced) 2 points Bovine human milk fortifier 2 points Amino Acid based formula or Hydrolyzed formula 3 points Bovine based formula

Maternal Factors Pick multiple factors 1 point Maternal cigarette use 2 points Placenta abruption 2 points Clinical chorioamnionitis – (maternal fever > or = 38C or 100.4F, uterine tenderness, maternal or fetal tachycardia, or

malodorous amniotic fluid or lab verification – placental pathology or maternal leukocytosis over 15000 cells/mm₃) given less than 6 hours prior to delivery for infants under 34 weeks gestation) 2 points maternal illicit drug use - Cocaine has strongest implication 2 points Preterm premature rupture of membranes (PPROM) (<37 weeks & prior to regular contractions) 2 points Prolonged rupture of membranes (> or = 18 hours) look for PROM in the chart 3 points Absent or reversed end diastolic flow to infant (present in fetal ultrasound) look for AREDF in the chart 3 points Incomplete or no antenatal glucocorticoid therapy (no steroids or steroid dose given less than 6 hours prior to delivery

for infants under 34 weeks gestation)

Infant Risk Factors Pick multiple factors 1 points Congenital heart disease/PDA 2 points Polycythemia (defined by hematocrit >60) 2 points Respiratory distress – more than 24 hours of assisted ventilation (ventilator, CPAP, HFNC) 2 points Red Blood Cell transfusion 3 points Antibiotics (equal to or more than 5 days) 3 points Sepsis 3 points Intrauterine Growth Restriction (IUGR) or Small for Gestational Age (SGA) – birth weight less than 10th percentile for

reference population 3 points Hypoxic events (acidosis evidenced by cord blood gas or blood gas, hypotension requiring saline bolus or

dopamine/dobutamine, five minute apgar less than 7, prolonged neonatal resuscitation – neopuff or bag/mask ventilation)

The science of caring for premature infants is evolving and the changes being

implemented can be difficult for nurses to integrate into practice in an efficient and confident

manner. Nursing practice changes are being impacted through the evolution of new complex

equipment, (bedside EEG, new smart pumps, complex new monitors, new respiratory equipment,

and multifunctioning infant transporters) a fast changing environment and advances in lifesaving

techniques allowing NICUs to attempt to change infant viability to 22 weeks gestation. The

development of huge quality data bases, comparing NICUs across the world, are allowing

NICUs to compare outcomes and bring to light new evidence based practice changes. Nurses are

now caring for babies born under 500 grams and the infants are surviving. In the whirlwind of

change and improvements there is one disease that has not decreased in incident or severity. The

disease is necrotizing enterocolitis (NEC). Necrotizing enterocolitis is a disease of the intestinal

tract causing inflammation and destruction of the bowel.

Clinical Problem: To help the mother understand her infant’s individual risk the nurse must be

able to identify each infant’s individual risk factors for NEC and feeding intolerance.

Clinical Question: Within the largest NICU quality data base in the United States, data shows

only 56% of VLBW infants are discharged still receiving their mother’s own milk. Would mothers

pump longer if they understood the individual risk of their own infant?

Framework: Using the eNEC tools to raise nurse awareness of each infant’s risk factors is one

way to improve the nurse’s ability to communicate to the mother her infant’s individual risks

for NEC. The eNEC tools were created from the evidence and formatted to optimize the

information for the bedside nurse.

NEC is a disease that virtually only exists in the NICU which creates a silo of silence around the

disease. This silence equals lack of disease awareness which may be part of the NEC problem.

When asking the clinical question: In the premature population what infants are most at risk

to develop feeding intolerance and NEC? Is it possible by identifying individual risk factors (raising

awareness) that are known to contribute to feeding intolerance/NEC and applying evidenced based

interventions to promote feeding tolerance (promoting mothers own milk) the result could be a

reduction in the incidence and severity of NEC and complications of feeding intolerance during the

infant’s hospitalization in the NICU?

The possibility exists that because NEC is relatively unknown to the public that the parents of

NICU infants cannot comprehend the dangers. NEC is a disease that is best prevented by mother’s

own milk (M.O.M.). M.O.M. colonizes the infant with a balance of bacteria, preventing overgrowth of

pathogenic bacteria.

NEC afflicts about 9% of the VLBW infants (Modi, 2015) and only about 50% of infants are

discharged still receiving M.O.M.

If the mother knew the health risks of NEC would she provide her milk longer?

There is very little information on this topic. Two parent organizations are developing

awareness: Morgan’s Fund (www.morgansfund.org) and the NEC Society (www.necsociety.org)