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Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in hospitalized infants. First classified through Bell staging in 1978, a number of additional definitions of NEC have been proposed in the subsequent decades. In this review, we summarize eight current definitions of NEC, and explore similarities and differences in clinical signs and radiographic features included within these definitions, as well as their limitations. We highlight the importance of a global consensus on defining NEC to improve NEC research and outcomes, incorporating input from participants at an international NEC conference. We also highlight the important role of patient-families in helping to redefine NEC.

Necrotizing enterocolitis (NEC) is a leading cause of mortality and morbidity in preterm newborns. Long-term neurodevelopment has become a critical area in NEC research, shifting the focus from survival alone to minimizing impairment as the primary goal. The mother's own milk is the optimal nutrition for preterm infants, and several well-controlled clinical trials have shown that human milk feeding can decrease the incidence of NEC. Clinical studies of exclusive human milk feeding are associated with significant reduction in rates of NEC. Some recent studies suggest that preterm infants who received human milk-based fortifier had an approximately 64% lower odds of developing NEC compared to those fed bovine-based fortifiers. Long-term neurodevelopment has become a critical area in NEC research, shifting the focus from survival alone to minimizing impairment as the primary goal. Quality measurement systems are a substantial investment in time and training but are required to ensure that people can collect, record, and interpret data correctly.

Necrotizing enterocolitis (NEC) is a serious disease of the intestinal tract affecting 5–10% of pre-term infants with up to 50% mortality in those that require surgery. There is wide variation in the rates and outcomes of NEC by race and ethnicity, and the reasons for this disparity are poorly understood. In this article, we review the epidemiology and discuss possible explanations for racial and ethnic differences in NEC. Most of the current evidence investigating the role of race in NEC comes from North America and suggests that Hispanic ethnicity and non-Hispanic Black race are associated with higher risk of NEC compared to non-Hispanic White populations. Differences in pre-term births, breastfeeding rates, and various sociodemographic factors does not fully account for the observed disparities in NEC incidence and outcomes. While genetic studies are beginning to identify candidate genes that may increase or decrease risk for NEC among racial populations, current data remain limited by small sample sizes and lack of validation. Complex interactions between social and biological determinants likely underly the differences in NEC outcomes among racial groups. Larger datasets with detailed social, phenotypic, and genotypic information, coupled with advanced bioinformatics techniques are needed to comprehensively understand racial disparities in NEC.

Necrotising enterocolitis (NEC) is a serious inflammatory bowel disease of prematurity with potentially devastating complications and remains a leading cause of morbidity and mortality among premature infants. In recent years, there has been accumulating data regarding benefits of using bowel ultrasound (BUS) in the diagnosis and management of NEC. Despite this, adoption of robust BUS programmes into clinical practice has been slow. As BUS is a relatively new technique, many barriers to implementation exist, namely lack of education and training for sonographers and radiologists, low case volume and unfamiliarity by clinicians regarding how to use the information provided. The aim of this manuscript is to provide a framework and a roadmap for units to implement BUS in day-to-day practice for NEC diagnosis and management.

Objective To compare length of stay (LOS) in neonatal care for babies born extremely preterm admitted to networks participating in the International Network for Evaluating Outcomes of Neonates (iNeo). Study design Data were extracted for babies admitted from 2014 to 2016 and born at 24 to 28 weeks of gestational age (n = 28 204). Median LOS was calculated for each network for babies who survived and those who died while in neonatal care. A linear regression model was used to investigate differences in LOS between networks after adjusting for gestational age, birth weight z score, sex, and multiplicity. A sensitivity analysis was conducted for babies who were discharged home directly. Results Observed median LOS for babies who survived was longest in Japan (107 days); this result persisted after adjustment (20.7 days more than reference, 95% CI 19.3-22.1). Finland had the shortest adjusted LOS (−4.8 days less than reference, 95% CI –7.3 to −2.3). For each week's increase in gestational age at birth, LOS decreased by 12.1 days (95% CI –12.3 to −11.9). Multiplicity and male sex predicted mean increases in LOS of 2.6 (95% CI 2.0-3.2) and 2.1 (95% CI 1.6-2.6) days, respectively. Conclusions We identified between-network differences in LOS of up to 3 weeks for babies born extremely preterm. Some of these may be partly explained by differences in mortality, but unexplained variations also may be related to differences in clinical care practices and healthcare systems between countries.

To investigate whether serum albumin (SA) concentration can predict the need for surgical intervention in neonates with necrotizing enterocolitis (NEC).Retrospective review of all cases with NEC Bell's stage 2 and 3 that were treated in a single center between 2009 and 2015. Data on patient demographics, clinical parameters, laboratory findings and surgical status were recorded. Receiver operating characteristics analysis was used to evaluate optimal cutoffs and predictive values.Overall, 151 neonates with NEC were identified. Of these, 132 (87.4%) had confirmed NEC Bell's stage 2. The median gestational age was 28.4 (range, 23.1-39.0) weeks and 69 (52.3%) had a birth weight of ≤1000 g. Sixty-eight (51.5%) underwent surgery, showing a sustained reduction in SA over time with significantly lower median SA levels compared to 64 (48.5%) cases that responded well to medical treatment (18.3 ± 3.7 g/L vs. 26.0 ± 2.0 g/L; P 0.001). SA concentration of ≤20 g/L on day 2 of NEC diagnosis was a significant predictor for surgery (OR 3.41; P = 0.019) with a positive predictive value of 71.4%.An SA concentration of ≤20 g/L on day 2 of the NEC disease process is associated with a higher likelihood for surgical intervention in neonates with NEC Bell's stage 2. SA, in combination with other clinical parameters and serological markers, may be a useful predictive tool for surgery in NEC.II.

OBJECTIVE To determine whether photo-protecting total parenteral nutrition in preterm infants influences arterial blood pressure differently according to gender. Blood pressure is influenced by complex mechanisms of vasomodulation. Oxidants are mediators and effectors in such reactions. Shielding total parenteral nutrition from light contributes to decrease the generation of peroxides. Girls may be better protected against an oxidant load than boys. We questioned whether shielding total parenteral nutrition may have cardiovascular effects that are influenced by gender. DESIGN A post hoc subgroup analysis of the effect of shielding parenteral nutrition from light. SETTING Neonatal intensive care unit. SUBJECTS Preterm infants

OBJECTIVE. The aim of our population-based study was to compare the mortality and morbidity of late-preterm infants to those born at term. Advancement in the care of extremely preterm infants has led to a shift of focus away from the more mature preterms, who are being managed as “near terms” and treated as “near normal.” Some recent studies have suggested an increased risk of mortality and morbidity in this group compared with infants born at term. However, there are few population-based mortality and morbidity statistics for this cohort, particularly reflecting current practice. METHODS. Using data from the British Columbia Perinatal Database Registry we analyzed all singleton births between 33 and 40 weeks’ gestation from April 1999 to March 2002 in the province of British Columbia, Canada. We divided this birth cohort into late preterm (33–36 weeks, n = 6381) and term (37–40 weeks, n = 88 867) groups. We compared mortality and morbidity data and associated maternal factors between the 2 groups. RESULTS. Stillbirth rate and perinatal, neonatal, and infant mortality rates were significantly higher in the late-preterm group. Infants in this group needed resuscitation at birth more frequently than those in the term group. Late-preterm infants had a significantly higher incidence of respiratory morbidity and infection and had a significantly longer duration of hospital stay. Maternal factors that were more common in the late-preterm group included chorioamnionitis, hypertension, diabetes, thrombophilia, prelabor rupture of membranes, primigravida, and teenage pregnancy. CONCLUSIONS. Our data support recent literature regarding neonatal mortality and morbidity in late-preterm infants and warrants a review of care for this group at the local, national, and global levels. Reorganization of services and increased resource allocation may be needed in most hospitals and community settings to achieve optimization of care for this group of infants.

Extrauterine growth retardation is a major clinical problem in very-low-birth-weight infants. Parenteral nutrition (PN) serves to achieve rapid maximal nutrition in early postnatal life. There is a lack of uniformity with regard to neonatal PN practice. The objective of this study is to ascertain current practice regarding neonatal PN prescription in the early postnatal period in the United Kingdom.A study questionnaire was e-mailed to neonatal pharmacists serving level 3 and major level 2 units in the United Kingdom between October 2005 and March 2006. Static numerical information regarding glucose, amino acids, and lipid prescription during the first 10 days of life was collected and compared with current recommendations.Fifty-two (81%) units responded to the questionnaire; 4 units were excluded for incomplete data. Twenty-six units (54%) initiated PN on day 1. Full PN was achieved by the median age of 6 days. Twelve units (25%) achieved full PN only by day 7 or later. Maximum median amino acids were 2.9 g/kg/d. Only 13 units (27%) prescribed/=3 g/kg/d, and 2 prescribed more than 3.5 g/kg/d. Nineteen units (39%) initiated lipids on day 1. Eleven units (23%) delayed lipids until day 3, and 2 units delayed lipids until day 4. In comparison to the recommended intake of calories and amino acids, the current median prescription would result in a cumulative deficit over the first 10 days of 420 kcal/kg and 11.9 g/kg, respectively.Our study suggests diverse practice with regard to neonatal PN prescription in the United Kingdom. Current neonatal PN practice entails a significant calorie and protein deficit during early postnatal life and warrants further review.

OBJECTIVE To compare rates of a composite outcome of mortality or major morbidity in very-preterm/very low birth weight infants between 8 members of the International Network for Evaluating Outcomes. STUDY DESIGN We included 58 004 infants born weighing

OBJECTIVE. Coagulase-negative Staphylococcus (CoNS) is the most frequent cause of late-onset sepsis in NICUs, but mortality is rare and morbidity is unusual. We report a new syndrome of CoNS sepsis characterized by significant morbidity and persistent bacteremia despite aggressive antibiotic therapy and no identified focus of infection.METHODS. We conducted a retrospective review of infants in the NICU with CoNS bacteremia between 2000 and 2002. Statistical analysis included an initial exploratory analysis followed by logistic regression. Microbiological identification of all isolates and molecular typing were performed.RESULTS. Thirty-one neonates with persistent CoNS bacteremia were compared with 60 randomly selected neonates from a group of 140 with nonpersistent CoNS bacteremia. The clinical manifestations at presentation, gestational ages, and birth weights were similar in the 2 groups. Thrombocytopenia was present in 26 (84%) neonates with persistent CoNS bacteremia but only in 8 (13%) neonates in the nonpersistent group. Central venous catheterization increased the risk for persistent CoNS bacteremia, but 42% of the persistent group was never catheterized. Staphylococcus epidermidis was the most common isolate in both groups. Molecular typing failed to identify a predominant clone.CONCLUSIONS. The syndrome of persistent CoNS septicemia is remarkable for thrombocytopenia and persistence in the absence of central venous catheterization. Clinical manifestations at presentation and demographic characteristics did not discriminate between the persistent and nonpersistent groups. We did not identify the emergence of a particularly virulent clone, but it is possible that some strains of CoNS have acquired the capacity to persist under different conditions.

A neonate presented with hyperphenylalaninemia (HPA), with a persistently elevated phenylalanine/tyrosine ratio. The HPA was responsive to tetrahydrobiopterin (BH4). His clinical course was dominated by liver failure, associated with perinatal hemochromatosis. He also developed renal tubulopathy. HPA has not previously been reported in association with any of these features. We investigated the etiology of his condition, and discuss the possibility that this represents a novel single-gene disorder.

Light-exposed total parenteral nutrition (TPN) generates peroxides that contribute to an oxidant load. Shielding TPN from light protects against lung remodelling. In preterm infants, photoprotection of TPN is associated with a 30% reduction in bronchopulmonary dysplasia in a post-hoc analysis. This analysis provides justification for a randomized controlled trial.

We report severe airway obstruction and distress at birth, in aterm newborn, caused by a congenital epiglottic cyst.Case reportA 3751 g female infant was born at 41 weeks to a 22-year-oldmother following an uneventful pregnancy. Antenatal ultrasoundscans at 18 and 22 weeks were reported normal. There wasevidence of respiratory distress and severe upper airway obstructionimmediately upon delivery. Direct laryngoscopy for intubationrevealed a white cystic mass in the oropharynx, obstructing thevisualization of the pharynx and, therefore, the glottis as well. Thepediatrician managed to move the mass out of the way, intubateorally and stabilize the airway. The infant was transferred to atertiary center for further management. Examination of the oralcavity revealed a white cystic mass filling the oropharynx.Transnasal fibro-optic laryngoscopy revealed the same but theexact site of origin could not be well delineated. Computedtomography (CT) was performed to rule out an intracranialconnection. The infant underwent surgery at 7 h of life.Examination of the oral cavity was undertaken in the operatingroom to try and establish exactly where the cyst attached andwhether it was broad based or on a stalk. This was difficult due tothe size of the cyst (Figure 1). The cyst was decompressed tofacilitate exposure and a revealed a viscous yellowish fluid. It wasestablished that the cyst was attached in a broad-based fashion tothe left lateral aspect of the epiglottis, into the vallecula, along thefree margin and lateral surface of the aryepiglottic fold and ontothe pharyngo-epiglottic fold.The covering of the cyst was then injected with 1% xylocainewith 1 in 200 000 epinephrine and deroofed. The sidewalls andbase of the cyst were dissected off of their respective underlyingstructures with microlaryngeal instruments utilizing high powermagnification of the microscope.The infant received broad-spectrum antibiotic coverage anddexamethasone in the perioperative period. Postoperative periodwas uneventful and the infant was successfully extubated after48 h. There was no evidence of upper airway obstruction or distresspostextubation and the infant was discharged home on day 4 oflife. At follow-up examination, 1 month postexcision, no evidenceof a recurrence was noted.Histological examination showed soft tissue lined by squamousepithelium, consistent with an epiglottic cyst.DiscussionCongenital laryngeal cysts are rare but may be fatal.

1808 www.thelancet.com Vol 366 November 19, 2005 A baby boy at 32 weeks’ gestation was born by spontaneous onset of preterm labour. He weighed 2265 g and had Apgar scores of 7 at 1 min and 9 at 5 min. He was clinically stable for 3 days and was started on enteral feeds. On the fourth day, we noted that he had temperature instability and abdominal distension with sanguineous gastric aspirates. He had poor perfusion, lactic acidaemia, and hyperglycaemia, and needed intubation and fluid resuscitation. Abdominal radiographs showed gastric and intestinal pneumatosis without any evidence of free intraperitoneal or portal venous air (figure). Leucopenia, neutropenia, and thrombocytopenia were also present, and we started the boy on antibiotics after blood culture. Because no organism was isolated, we did not do a laparotomy. He improved over the next month but became intolerant to the enteral feeds. We did a contrast study, which showed small bowel obstruction. At laparotomy we found several old small bowel perforations with associated strictures, and resected two small ileal segments. His stomach and duodenum did not show any abnormality. Histopathology was consistent with necrotising enterocolitis with perforation, and a rectal biopsy showed submucosal ganglia with normal cholinesterase pattern. Although necrotising enterocolitis is common in babies in neonatal intensive care, gastric pneumatosis is rare and usually follows cardiac surgery, pyloric or duodenal stenosis, or intramural misplacement of a feeding catheter. Gastric pneumatosis in a preterm infant

[Figure][1] Figure 1. A preterm infant born at 27 weeks' gestation had stable ventilatory requirements until day 3, when a pulmonary hemorrhage developed. Positive end-expiratory pressure was increased from 5 to 7 mm Hg. On day 10 a left-sided pneumothorax developed that required