Ask the Experts
Q) I would like to know about developmental delays caused by NEC little elaborately. I was told kids with NEC catch up eventually but was not told what to expect and how to support the kid. So would like to know more from the experts please?
A) All preterm infants benefit from input from specialist teams keeping an eye on their development and from parents who are actively engaged in their progress. Infants who had NEC can experience physical or learning/emotional problems, and physiotherapists and community paediatricians are important to help support parents. Some children do ‘catch up’ but some will have longer term difficulties. In the UK community paediatricians are key to the longer term support for these families and children.
Q) Is it better to wait with operation when we are not 100% sure whether gut perforated or not?
A) We try very hard not to wait for the gut to perforate before going to surgery, as the baby is likely to be more sick after this has happened. If a baby is not improving with obvious signs of NEC we would not wait for a perforation, but would perform surgery to try and prevent this. If babies are taken for surgery ‘too early’ there is a risk either that the surgeon will remove inflamed bowel (that might have got better if left alone) or they might not remove enough bowel to make the baby better (so the baby might need a second operation). So the timing of surgery is very important, but very difficult to know exactly when it is best performed. We need more research studies to find out. One of the most important factors is being looked after in a large NICU where there are likely to be more staff with more combined experience, and where surgeons can also review the baby. This is one of the reasons many of us feel that we need fewer but larger sized neonatal units in the UK to care for the most vulnerable infants.
Q) I recently saw that NEC causes developmental delays. I would like to know more about this.
A) If you look across populations of preterm babies with and without NEC in general the babies who experienced NEC are more likely to have problems than those who did not. This does not mean that every individual baby will have problems though. We think that this relates to the chemicals that are released as a result of the inflammatory processes of NEC that affect the brain. We know of many children who had serious NEC that required removal of diseased bowel, who have grown up and developed normally. Understanding how we can ‘protect’ the brain during NEC is an important research area.
Q) Can we predict if a normal, mild infection can transform into NEC? Can we pin down the exact moment when it happened?
A) Not at the moment. There are some babies who appear to have a period of general un-wellness in the 1 – 2 days before NEC and have already started antibiotics and then it becomes clear that they have developed NEC. There are research studies looking to see whether analysing the pattern of chemicals or bacteria in the stool or urine can predict which babies are at highest risk of developing NEC. We need more research to understand this better.
Q) Can for example a set of tummy problems with vomiting (which then seem to settle down) be an early sign of NEC developed few days later?
A) Because lots of preterm babies will take a little time to tolerate their feeds, and some will have aspirates or small possets as part of this, most babies will not go on to develop NEC. However a baby might have normal aspirates/possets one day and then develop NEC the next. Babies who have already learned to tolerate their feeds and then develop problems need a more careful examination to make sure this is not the beginning of NEC.
Q. Is it possible for a small dose of formula to trigger NEC in a baby which was breast fed previously? Has this been proven somewhere? I’ve read that formula alters gut's microbiome (and so called gut virginity) for months. Can this be related?
A. There is no data to specifically answer whether a small amount of formula is harmful. What we know is that the more of Mum’s own milk (MOM) a baby can get the lower the chances of NEC. It’s not the same though to be able to say that a small amount of formula can ‘trigger’ NEC. We do know that the gut bacteria are different in breast and formula fed babies, but they also change in one baby day to day without any obvious triggers. A recent large trial conducted in the Netherlands showed no difference in the amount of NEC when babies either received formula or donor milk to make up any shortfall in MOM over the first 10 days. This suggests that small amounts of formula do not trigger early NEC, and support the idea that the more MOM received, the healthier the baby.
Q. Why statistically do formula fed babies have higher risk of NEC? Is it because bm actively fights infection or because by removing bm we remove protecting layer from gut lining?
A. Breast milk (especially MOM) is full of biologically active components that together help protect against NEC. We know that giving extra of just one component (rather than all of them as part of breast milk) does not prevent NEC in the way that we hoped it would. The ELFIN study just looked at this for lactoferrin (the major protein component of colostrum), giving additional lactoferrin to more than 2,000 infants less than 32 weeks in the UK. Sadly additional lactoferrin did not protect preterm infants against NEC. However, the extra lactoferrin used in this study was from cow’s milk rather than from humans. It seems more likely that human milk is ‘good’ rather than formula milk being ‘bad’. i.e. the higher rate of NEC in formula fed babies may be because they are getting less MOM.