Necrotizing Enterocolitis in the Premature Infant

Abstract

Necrotizing enterocolitis as a usually fatal disease of premature infants has been reported with increasing frequency in recent years, primarily in Europe (2, 11, 12, 14, 15, 23). Though the published cases have appeared under diverse titles including neonatal appendicitis (4, 18, 22), peritonitis (12), colitis (21), ileitis (1), pneumatosis intestinalis (20), or portal vein gas in infants (10, 24), we feel all reflect a basically similar disease process. The current report is based on a study of 21 cases of enterocolitis in newborn premature infants seen between 1954 and 1964; 7 were found in a six-month period in 1963. A more detailed study of the clinical and pathologic findings will be reported separately (9). Clinical Features More than 2,000 infants were admitted to the premature nursery of The Babies Hospital from 1954 to 1964. Seventeen died of enterocolitis (0.9 per cent), and 4 survived. Usually weighing under 1,500 grams at birth, the babies showed a similar clinical pattern. They seemed well during the first forty-eight to seventy-two hours of life with no signs of respiratory distress or fever, and feedings were well tolerated. Following this variable period of well-being, delayed gastric emptying, bile-tinged emesis and gastric residue, and mild to severe abdominal distention developed; blood-streaked stools were then passed, though actual diarrhea was uncommon Despite vigorous supportive and antibiotic therapy, the usual picture was one of deterioration with apneic spells, jaundice, shock, and death. Maternal records revealed a high incidence of prenatal fever, prolonged (over twenty-four hours) rupture of the membranes, or infected amnionic contents. Cultures of blood, spinal fluid, stools were positive in more than half the mothers. Escherichia coli, B. proteus, and A. aerogenes were the usual organisms. Typing of E. coli was not undertaken (7, 15). The relationship to the enterocolitis of these signs of maternal and infant infection and the gram-negative flora found on culture will be discussed later (7, 15). Infants with more severe distention were sometimes surgically explored, either for perforation encountered on roentgen study or for what was thought to be possible aganglionic megacolon of part or all the colon. As will be seen, necrotizing enterocolitis may simulate the clinical and roentgen signs of neonatal aganglionosis to an amazing degree. Of the 4 survivors, 3 were surgically treated by excision of necrotic bowel; 1 survived with medical management; all the other infants died with local and generalized disease. Surgtcal and Postmortem Pathologic Findings Laparotomy or postmortem examination revealed a necrotizing enterocolitis of variable severity, most commonly involving the ileum, appendix, and right colon. In some cases the stomach, midgut, and colon were totally involved.