Elsevier

Journal of Pediatric Surgery

Volume 47, Issue 11, November 2012, Pages 2111-2122
Journal of Pediatric Surgery

Review Article
Treatment of necrotizing enterocolitis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

https://doi.org/10.1016/j.jpedsurg.2012.08.011Get rights and content

Abstract

Objective

The optimal treatment of necrotizing enterocolitis (NEC) is a common challenge for pediatric surgeons. Although many studies have evaluated prevention and medical therapy for NEC, few guidelines for surgical care exist. The aim of this systematic review is to review and evaluate the currently available evidence for the surgical care of patients with NEC.

Methods

Data were compiled from a search of PubMed, OVID, the Cochrane Library database, and Web of Science from January 1985 until December 2011. Publications were screened, and their references were hand-searched to identify additional studies. Clinicaltrials.gov was also searched to identify ongoing or unpublished trials. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee proposed six questions deemed pertinent to the surgical treatment of NEC. Recent Cochrane Reviews examined three of these topics; a literature review was performed to address the additional three specific questions.

Results

The Cochrane Reviews support the use of prophylactic probiotics in preterm infants less than 2500 grams to reduce the incidence of NEC, as well as the use of human breast milk rather than formula when possible. There is no clear evidence to support delayed initiation or slow advancement of feeds. For surgical treatment of NEC with perforation, there is no clear support of peritoneal drainage versus laparotomy. Similarly, there is a lack of evidence comparing enterostomy versus primary anastomosis after resection at laparotomy. There are little data to determine the length of treatment with antibiotics to prevent recurrence of NEC.

Conclusion

Based on available evidence, probiotics are advised to decrease the incidence of NEC, and human milk should be used when possible. The other reviewed questions are clinically relevant, but there is a lack of evidence-based data to support definitive recommendations. These areas of NEC treatment would benefit from future investigation.

Section snippets

Questions

In an effort to summarize and categorize current therapies for infants with NEC, the American Pediatric Surgical Association (APSA) Outcomes and Clinical Trials Committee posed several questions which are pertinent to the daily care of infants with NEC. These questions were chosen based on common clinical scenarios.

  • 1.

    Does the use of prophylactic probiotics reduce the rate of NEC in newborn infants?

  • 2.

    Does exclusive use of human breast milk rather than formula affect the rate of NEC in newborn

Results

The Cochrane Collaborative addressed the first three of these questions with recent systematic reviews that are summarized in this report. The last three questions were evaluated with the methods described.

Summary of findings

In conclusion, definitive studies to aid the pediatric surgeon with care of infants with NEC are lacking (Appendix). Several studies do support probiotics as being effective in preventing NEC, and the Cochrane Collaboration recommends routine use in practice, though the precise formulation and timing is not determined. Human milk generally should be fed to preterm infants when available, as there is an increased risk of NEC when formula is used. Feeds can be initiated early in life, which is

References (69)

  • L. Fasoli et al.

    Necrotizing enterocolitis: extent of disease and surgical treatment

    J Pediatr Surg

    (1999)
  • D.M. Griffiths et al.

    Primary anastomosis for necrotising enterocolitis: a 12-year experience

    J Pediatr Surg

    (1989)
  • A. Cooper et al.

    Resection with primary anastomosis for necrotizing enterocolitis: a contrasting view

    J Pediatr Surg

    (1988)
  • W.J. Pokorny et al.

    Necrotizing enterocolitis: incidence, operative care, and outcome

    J Pediatr Surg

    (1986)
  • M.D. Stringer et al.

    Recurrent necrotizing enterocolitis

    J Pediatr Surg

    (1993)
  • R.G. Faix et al.

    A randomized, controlled trial of parenteral clindamycin in neonatal necrotizing enterocolitis

    J Pediatr

    (1988)
  • "The Oxford 2011 Levels of Evidence". Oxford Centre of Evidence-Based Medicine

  • K. Slim et al.

    Methodological index for non-randomized studies (MINORS): development and validation of a new instrument

    ANZ J Surg

    (2003)
  • K. Alfaleh et al.

    Probiotics for prevention of necrotizing enterocolitis in preterm infants

    Cochrane Database Syst Rev

    (2011)
  • M.J. Bell et al.

    Alterations in gastrointestinal microflora during antimicrobial therapy for necrotizing enterocolitis

    Pediatrics

    (1979)
  • F.N. Sari et al.

    Oral probiotics: Lactobacillus sporogenes for prevention of necrotizing enterocolitis in very low-birth weight infants: a randomized, controlled trial

    Eur J Clin Nutr

    (2011)
  • M. Samanta et al.

    Prophylactic probiotics for prevention of necrotizing enterocolitis in very low birth weight newborns

    J Trop Pediatr

    (2009)
  • R. Mohan et al.

    Effects of Bifidobacterium lactis Bb12 supplementation on intestinal microbiota of preterm infants: a double-blind, placebo-controlled, randomized study

    J Clin Microbiol

    (2006)
  • P.D. Reuman et al.

    Lack of effect of Lactobacillus on gastrointestinal bacterial colonization in premature infants

    Pediatr Infect Dis

    (1986)
  • M.R. Millar et al.

    Enteral feeding of premature infants with Lactobacillus GG

    Arch Dis Child

    (1993)
  • P. Manzoni et al.

    Oral supplementation with Lactobacillus casei subspecies rhamnosus prevents enteric colonization by Candida species in preterm neonates: a randomized study

    Clin Infect Dis

    (2006)
  • H.C. Lin et al.

    Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants

    Pediatrics

    (2005)
  • H.C. Lin et al.

    Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants: a multicenter, randomized, controlled trial

    Pediatrics

    (2008)
  • H. Kitajima et al.

    Early administration of Bifidobacterium breve to preterm infants: randomised controlled trial

    Arch Dis Child Fetal Neonatal Ed

    (1997)
  • C. Dani et al.

    Probiotics feeding in prevention of urinary tract infection, bacterial sepsis and necrotizing enterocolitis in preterm infants. A prospective double-blind study

    Biol Neonate

    (2002)
  • M.A. Quigley et al.

    Formula milk versus donor breast milk for feeding preterm or low birth weight infants

    Cochrane Database Syst Rev

    (2007)
  • D.P. Davies

    Adequacy of expressed breast milk for early growth of preterm infants

    Arch Dis Child

    (1977)
  • S.J. Gross

    Growth and biochemical response of preterm infants fed human milk or modified infant formula

    N Engl J Med

    (1983)
  • A. Lucas et al.

    Multicentre trial on feeding low birthweight infants: effects of diet on early growth

    Arch Dis Child

    (1984)
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