Necrotizing Enterocolitis (NEC)

A Guide for Affected Families by Baltimore Necrotizing Enterocolitis Lawyer Mark Kopec

Necrotizing enterocolitis (NEC) is a dangerous and rapidly developing intestinal disease. It primarily affects premature infants, though it can also occur in full-term babies. NEC is inflammation and injury to the intestinal lining. This injury can lead to the death (necrosis) of intestinal tissue. In severe cases, a hole (perforation) in the intestinal wall can then occur. This hole allows bacteria normally contained within the intestine to leak into the abdomen. The leak causes widespread infection (peritonitis) and potentially deadly sepsis. If your child is injured, you may need Baltimore necrotizing enterocolitis lawyer Mark Kopec at the Kopec Law Firm.

Understanding NEC is crucial for parents, especially those whose infants are at high risk. Prompt recognition of symptoms and appropriate medical intervention are key to better outcomes. Sadly, in some instances, delayed diagnosis or mismanagement of NEC can form the basis of a birth injury medical malpractice claim. This page aims to provide comprehensive information about NEC, from its causes and symptoms to treatment, long-term effects, and instances where medical negligence may play a role.

What is Necrotizing Enterocolitis and What Causes It?

Necrotizing enterocolitis often results from a combination of factors that compromise the integrity of an infant’s immature intestinal tract.

Key Contributing Factors

• Prematurity: This is the most significant risk factor. Premature infants have underdeveloped intestines that are more susceptible to injury and infection. Their digestive systems are not yet fully equipped to process feedings or fight off harmful bacteria. The earlier a baby is born, and the lower their birth weight, the higher their risk of developing NEC.
• Intestinal Ischemia (Reduced Blood Flow): Insufficient blood flow to the intestines can damage the tissue, making it vulnerable to bacterial invasion. This can occur due to a difficult birth resulting in oxygen deprivation (asphyxia), low blood pressure, or other conditions affecting blood circulation. The body of a stressed newborn may increase blood flow to vital organs like the brain and heart, taking it from the gut.
• Enteral Feeding (Especially Formula): While breast milk is protective, formula feeding, particularly cow’s milk formulas, can increase the risk of NEC in premature infants. Formula can be harder for an immature gut to digest and may alter the balance of bacteria in the intestines.

Additional Factors

• Infection: Bacteria or viruses can directly infect the intestinal wall, triggering the inflammatory cascade that leads to NEC. Outbreaks of NEC have occurred in neonatal intensive care units (NICUs), suggesting a possible infectious component.
• Difficult Birth and Oxygen Deprivation: A traumatic or prolonged birth process that leads to reduced oxygen supply to the baby can compromise intestinal blood flow, increasing NEC risk.
• Blood Transfusions: Some studies have suggested a possible link between blood transfusions and the development of NEC, although the exact nature of this association is still being researched. It may be related to the underlying anemia necessitating the transfusion rather than the transfusion itself.
• Existing Medical Conditions: Infants with other health issues, such as congenital heart defects or sepsis, may also be at higher risk.

NEC typically develops within the first two to six weeks of life, often after milk feedings have begun. The condition can progress rapidly, making early detection critical.

Recognizing the Signs: Symptoms of NEC – Baltimore Necrotizing Enterocolitis Lawyer Mark Kopec

The symptoms of NEC can vary from subtle to severe. Vigilant monitoring by healthcare professionals is essential.

Common Symptoms Include:

• Abdominal Distension (Swelling): The baby’s belly may appear bloated, firm, or tender to the touch.
• Feeding Intolerance: Difficulty feeding, refusing feeds, or increased residuals (undigested milk) in the stomach before the next feeding.
• Vomiting: Vomit may be green (containing bile) or, in some cases, bloody.
• Bloody Stools: This is a significant warning sign.
• Diarrhea or Changes in Bowel Habits:
• Lethargy or Apnea: The baby may seem unusually tired, have pauses in breathing (apnea), or a slowed heart rate (bradycardia).
• Temperature Instability: Difficulty maintaining a normal body temperature (either too high or too low).
• Signs of Infection: Rapid heart rate, low blood pressure, and poor perfusion (pale or mottled skin).
• Reddish or Bluish Discoloration of the Abdomen: This can indicate severe inflammation or perforation.

If any of these symptoms are observed, particularly in a premature infant, immediate medical attention is required.

Diagnosis: Identifying NEC

Prompt diagnosis of NEC is crucial for starting timely treatment and better chances of a favorable outcome. Several types of doctors may collaborate to diagnose NEC:

• Neonatologists: Specialists in the care of newborn infants, especially those who are ill or premature. They are often the primary caregivers in the NICU and are typically the first to suspect and investigate NEC.
• Pediatricians: While less common for the initial diagnosis if the baby is in a NICU, a pediatrician might be involved if symptoms develop after discharge or in a full-term infant.
• Pediatric Radiologists: These specialists interpret imaging studies, which are key to diagnosing NEC.

Diagnostic Tests Commonly Used

• Abdominal X-rays: This is the primary imaging tool used to diagnose NEC. X-rays can show characteristic signs such as:
  • Pneumatosis intestinalis: Gas cysts or bubbles in the wall of the intestine. This is a typical sign of NEC.
  • Portal venous gas: Gas in the veins leading to the liver, indicating more severe disease.
  • Pneumoperitoneum: Free air in the abdominal cavity, which signifies a bowel perforation – a surgical emergency.
  • Dilated bowel loops.
• Blood Tests: These can help assess the severity of the illness and look for signs of infection or complications:
  • Complete Blood Count (CBC): May show a high or low white blood cell count (indicating infection or stress), a low platelet count (thrombocytopenia), or anemia.
  • C-Reactive Protein (CRP): An inflammatory marker that is often elevated.
  • Blood Cultures: To check for bacteria in the bloodstream (sepsis).
  • Electrolyte Levels and Blood Gas Analysis: To assess for metabolic acidosis (an imbalance in the body’s acid-base balance) and electrolyte disturbances.
• Stool Tests: Testing the stool for occult (hidden) blood.
• Abdominal Paracentesis (less common): In some critical situations, a needle may be inserted into the abdominal cavity to withdraw fluid. The presence of intestinal fluid can confirm a perforation.

Baltimore necrotizing enterocolitis lawyer Mark Kopec can discuss the tests your child should have received.

Treatment: Managing NEC

The treatment for NEC depends on the severity of the condition. The primary goals are to stop the progression of the disease, prevent or treat infection, and support the infant’s overall health. A multidisciplinary team often treats the child:

• Neonatologists: Continue to oversee the infant’s medical care in the NICU.
• Pediatric Surgeons: Become involved if surgical intervention is necessary.
• Pediatric Gastroenterologists: Gives long-term management of intestinal issues.
• Registered Dietitians: Provide expertise in nutritional support, which is critical.
• Pharmacists: Assist with medication management, particularly antibiotics and pain relief.
• Nurses: Provide round-the-clock critical care.

Treatment Approaches

Medical (on-Surgical) Management:

For less severe cases, or as an initial approach:

• Bowel Rest: All oral or tube feedings are stopped immediately to allow the intestines to rest and heal.
• Intravenous (IV) Nutrition and Fluids: The baby receives total parenteral nutrition (TPN), a specialized IV solution containing all necessary nutrients (glucose, amino acids, lipids, vitamins, and minerals), and IV fluids to maintain hydration.
• Nasogastric (NG) or Orogastric (OG) Tube Decompression: A tube is inserted through the nose or mouth into the stomach to remove air and fluid, relieving abdominal distension and reducing pressure on the intestines.
• Broad-Spectrum Antibiotics: Administered by IV to treat or prevent infection. The choice of antibiotics may be changed based on blood culture results.
• Supportive Care: This includes monitoring vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, temperature), providing oxygen or mechanical ventilation if breathing is affected, and managing pain.
• Serial Abdominal X-rays and Blood Tests: To monitor the progression of the disease and response to treatment.

Surgical Management

Surgery is required if there is evidence of bowel perforation, if the infant’s condition worsens despite medical management, or if a large portion of the intestine is clearly necrotic.

• Exploratory Laparotomy: The surgeon makes an incision in the abdomen to directly examine the intestines. Dead or perforated sections of the bowel are removed (bowel resection). The surgeon aims to preserve as much healthy bowel as possible.
• Ostomy Creation (e.g., ileostomy or colostomy): In many cases, after removing the damaged bowel, the surgeon may bring the end(s) of the healthy intestine to an opening on the abdominal wall (a stoma). Waste then collects in an external bag. This allows the remaining bowel to heal before a potential second surgery to reconnect the bowel (ostomy takedown) weeks or months later.
• Primary Anastomosis: In some select cases, if the infant is stable and the extent of disease is limited, the surgeon may be able to remove the diseased bowel and immediately reconnect the healthy ends.
• Peritoneal Drainage: For very small, unstable infants who may be too sick for a full laparotomy, a doctor places a drain into the abdominal cavity under local anesthesia at the bedside. This can help remove infected fluid and air, potentially stabilizing the baby for later surgery or, in rare cases, serving as the sole intervention.

Recovery after surgery can be lengthy, and the infant will continue to require intensive care and nutritional support.

Outcomes and Possible Permanent Effects with Baltimore Necrotizing Enterocolitis Lawyer Mark Kopec

The outcomes for infants with NEC vary widely depending on how severe the disease, the infant’s gestational age and overall health, and the timeliness and effectiveness of treatment.

• Full Recovery: Many infants, especially those with milder forms of NEC that respond well to medical management, can make a full recovery and experience no long-term feeding problems.
• Mortality: Unfortunately, NEC can be fatal, particularly in very premature infants or when bowel perforation and widespread sepsis occur. Mortality rates can range from 20% to over 50% in surgical cases.

Potential Long-Term Complications and Permanent Effects:

• Short Bowel Syndrome (SBS): This is one of the most significant long-term complications. If a large portion of the intestine had to be surgically removed, the remaining bowel may not be sufficient to absorb adequate nutrients from food. Infants with SBS often require long-term TPN, which carries its own risks, including liver disease (TPN-associated cholestasis) and bloodstream infections. They may also need specialized formulas and, in some cases, intestinal transplantation.
• Intestinal Strictures: As the damaged intestine heals, scar tissue can form, leading to a narrowing (stricture) of the bowel. Strictures can cause blockages, abdominal pain, vomiting, and difficulty with feedings. The baby may need further surgery to repair or remove strictures.
• Adhesions: Scar tissue can also form bands (adhesions) between loops of intestine or other abdominal organs, potentially causing bowel obstructions later in life.
• Malabsorption and Nutritional Deficiencies: Even without SBS, damage to the intestine can impair its ability to absorb specific nutrients, leading to deficiencies that can affect growth and development.
• Growth Failure and Developmental Delays: Chronic illness, prolonged hospitalization, nutritional challenges, and complications like SBS can impact an infant’s growth and neurodevelopment. Survivors of severe NEC are at higher risk for developmental delays, learning difficulties, and cerebral palsy.
• Neurodevelopmental Impairment: Studies have shown an association between NEC and an increased risk of neurodevelopmental problems, regardless of the presence of other risk factors common in premature infants. The systemic inflammation and stress of the illness can affect brain development.

Additional Effects

• Recurrent NEC: In some cases, NEC can recur.
• Feeding Aversion and Oral Aversion: Prolonged periods of bowel rest, uncomfortable procedures, and IV nutrition can also sometimes lead to difficulties with transitioning to oral feedings.
• Impact on Quality of Life: Children who have survived severe NEC may face ongoing medical challenges, frequent hospital visits, and dietary restrictions, which can impact their quality of life and that of their families.

Long-term follow-up with pediatric gastroenterologists, surgeons, nutritionists, and developmental specialists is often necessary for children who have had NEC.

Medical Malpractice Claims Related to NEC

Medical negligence may contribute to the development or worsening of NEC or lead to a poorer outcome. A medical malpractice claim may arise if a healthcare provider’s actions or inactions fell below the accepted standard of care, directly causing harm to the infant.

Types of Medical Malpractice Claims with Baltimore Necrotizing Enterocolitis Lawyer Mark Kopec

1. Misdiagnosis or Failure to Timely Diagnose NEC:
   • Ignoring or misinterpreting early signs and symptoms (e.g., abdominal distension, bloody stools, feeding intolerance, vomiting bile).
   • Delaying necessary diagnostic tests like abdominal X-rays when symptoms are present.
   • Failing to recognize the increased risk in premature infants or those with specific risk factors.
2. Failure to Properly Treat NEC:
   • Delaying the initiation of bowel rest and IV antibiotics once the doctor suspects or diagnoses NEC.
   • Not providing adequate nutritional support (TPN) during bowel rest.
   • Failing to promptly consult with a pediatric surgeon when surgical intervention is indicated (e.g., signs of perforation or clinical deterioration).
   • Surgical Errors during procedures or inadequate post-operative care.
3. Negligence Contributing to Risk Factors for NEC:
   • Mismanagement of a high-risk pregnancy or delivery leading to severe prematurity or birth asphyxia (oxygen deprivation). These are risk factors for NEC.
   • Inappropriate feeding practices, such as aggressively advancing formula feeds in a high-risk premature infant against established protocols or using certain types of formula known to increase NEC risk in premature babies without proper justification or informed consent.
   • Failure to implement appropriate infection control measures in the NICU, potentially contributing to an outbreak.

Additional Claims

1. Failure to Monitor High-Risk Infants:
   • Inadequate monitoring of premature infants for the subtle early signs of NEC.
   • Not closely tracking feeding tolerance, abdominal exams, and stool patterns in at-risk babies.
2. Lack of Informed Consent Regarding Feeding Choices:
   • In some situations, particularly concerning the use of cow’s milk formulas in very premature infants, failing to inform parents of the known risks of NEC associated with these formulas compared to exclusive human milk diets, and the availability of alternatives like donor breast milk.

Proving medical malpractice requires that a medical provider breached the standard of care (i.e., acted in a way that a reasonably prudent medical provider in a similar situation would not have) and that this breach directly caused the baby’s injuries and damages. These cases are complex and typically require expert expert witness testimony from medical professionals.

Next Step: Call Baltimore Necrotizing Enterocolitis Lawyer Mark Kopec

If you believe your child developed NEC or suffered a worse outcome due to poor medical care, consult with a birth injury attorney experienced in medical malpractice cases. We can help evaluate your situation, obtain medical records, and determine if a valid claim exists.

Visit our free consultation page or video. Then contact the Kopec Law Firm at 800-604-0704 to speak directly with Attorney Mark Kopec. He is a top-rated Baltimore birth injury lawyer. The Kopec Law Firm is in Baltimore and pursues birth injury cases throughout Maryland and Washington, D.C.