HIGH DEPENDENCY CARE OF THE NEW BORN. The following discussion will analyse the care of a baby who I have recently looked after in the high dependency who developed necrotising entero colitis(NEC) and consequently had to be re admitted to the NICU.

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Registration NO:   100252125

Module NO        :   SNM3115

Unit Leader        :   Angela Thurlby

Word Count       : 2022

The following discussion will analyse the care of a baby who I have recently looked after in the high dependency who developed necrotising entero colitis(NEC) and consequently had to be re admitted to the NICU. According to Sankaran (2004) NEC is an inflammatory disease of the bowel, predominantly affecting premature infants but it sometimes occurs in ‘cohorts’. Whilst caring for the baby he became ill with a profound bradycardia and on turning him over he looked pale, cyanosed with a mottled skin and distended abdomen. He weighed only 1050g, and had previously been moved from ITU to high dependency because he was tolerating full feeds of expressed breast milk (EBM). According to Boxwell (2010) NEC is characterised by transmural intestinal inflammation, ischaemia, necrosis and sometimes perforation which affects one to eight per cent of infants admitted to NICU. As a result of his condition the baby was transferred back to intensive care unit for close observation and further investigation. He had been born at 24 weeks +5 days gestation with a birth weight of 590g but was now 42 days old. He had also had a blood transfusion the previous day and his mother had prolonged rupture of membranes. She had also received two doses of steroids prior to delivery.

The actual cause of NEC is unknown but there are factors that are thought to contribute to the development of NEC such as birth asphyxia, umbilical catheterisation, artificial milk feeding and early feeding (Thomas and Harvey 1997). Blood transfusion, polycythemia and patent ductus arteriosus are other factors (Pearse and Roberton,1998). Lin &Stoll (2006) suggests that giving feeds with high osmolarity or increasing the volume or rate of increase, can harm the bowel mucosa causing intra-mural milk providing a substrate for bacteria.

According to Rennie and Roberton (2002) the severity of the condition can vary ranging from a stage where NEC is suspected to very severe symptoms, and lesions can occur anywhere from the stomach to the rectum and in some cases multiple areas may be affected. Several of these predisposing factors were noticed in the baby discussed. He was premature and had respiratory distress syndrome and a PDA, and also had undergone umbilical catheterisation. The feed were increased rapidly due to his poor weight gain. According to McCormick (2000) neonatal nurses may also observe some early signs noting that the baby ‘doesn’t seem right’, or is experiencing difficulty absorbing the feed. She suggests that these are important observations of the possible early signs and the medical team need to be made aware of these if concerned.

As a result of the experience of caring for this baby I have decided to focus on the role of feeding as a factor in the pathogenesis of NEC, for this discussion. I need to increase my knowledge on this issue because neonatal nurses can often detect the early signs of NEC based on their observation of the baby’s feeding tolerance. The predisposing factors that contribute to the development of NEC will also be discussed. In relation to the baby in this case his feeding was increased rapidly as he also had a blood transfusion the previous day and had started to have episodes of bradycardia. As identified previously he had a number of other predisposing factors such as prematurity, maternal steroids, PDA, blood transfusion and an umbilical catheter (Osborn 2005). Lucas and Cole (1990) carried out a prospective multicentre study on 926 preterm infants finding that cases of confirmed NEC was 6-10 times more common in exclusively formula fed babies than those who had been fed on breast milk alone and 3 times more common than in those who received formula plus breast milk. They also found a lower frequency of NEC was associated with delayed enteral feeding in formula fed infants. Morgan, Young Land McGuire (2011) in a Cochrane review abstract found that slowly increasing the volume of milk feed to very low birth weight infants did not have any effect on the risk of NEC.

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According to Chabra (2006) advanced practices and monitoring and the use of specialist milks have reduced the risk of NEC in the first phase but it can still present weeks later. Osborn (2005) found that even though premature infants will be exposed to common risk factors, NEC develops in only 2-4 percent of infants admitted to NICU and that 90 % of reported cases occur in the preterm infant.  Beeby and Jeffrey (1992) highlight that NEC  appears to increase with decreasing  gestation and can be found in  10% of  infants born at 25 weeks  gestation compared to  0.03% in term ...

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