Poor feeding and feeding intolerance in the neonate — case

Case summary

A 12-day-old infant born at 27 weeks' gestation, weighing 920 g, is on the neonatal unit on advancing expressed breast milk feeds at 120 mL/kg/day. Over the shift, the pre-feed gastric residual has risen to exceed the feed volume and is bile-stained, the abdomen has become fuller, and the infant has had three apnoeic spells requiring stimulation. The nursing staff are concerned. [1] [2]

Candidate tasks

1. Take a focused history and examine the infant; formulate a one-line problem representation. [1]
2. Outline your immediate and stepwise management of the suspected necrotising enterocolitis. [2]
3. Counsel the parents about the cause, the immediate plan, and the longer-term outlook. [3]

Focused history and examination

• History: gestation and birthweight (27 weeks, 920 g — extreme prematurity, the dominant NEC risk factor); route and type of feeding (expressed breast milk, advancing — protective but not protective enough); age at onset (day 12, typical late onset); perinatal factors (antenatal steroids, mode of delivery, chorioamnionitis); meconium passage; medications (indomethacin or ibuprofen for a ductus, caffeine, antibiotics). [1]
• Systemic observations: temperature (instability), heart and respiratory rate, oxygen saturation, capillary refill and perfusion, frequency of apnoea and bradycardia. Hypothermia, tachycardia, poor perfusion, and rising apnoea burden signal systemic involvement. [5]
• Abdominal examination: inspect for distension, symmetry and abdominal wall colour (erythema, induration, shininess); palpate gently for tenderness, guarding, palpable or fixed loops; check the hernial orifices and inspect the perineum. [1]
• Gastric residual: aspirate before the feed and judge the volume, colour and character. Here the residual is large, increasing, and bile-stained — a red flag. [1]

One-line summary: "A 12-day-old, 27-week, 920-g preterm on advancing expressed breast milk feeds, with a large bile-stained residual, abdominal distension and new apnoea — suspected necrotising enterocolitis; make nil by mouth, decompress, resuscitate, image." [2]

Immediate and stepwise management

• Stop feeds and decompress: make nil by mouth; pass a large-bore orogastric tube on free drainage. [2]
• Resuscitate: establish intravenous access, give isotonic crystalloid boluses (10 mL/kg) titrated to perfusion, correct glucose and temperature, and start broad-spectrum empiric antibiotics covering Gram-positive and Gram-negative enteric organisms (guided by the local unit protocol). [2]
• Investigate: plain abdominal radiograph (anteroposterior plus a left-lateral-decubitus view) looking for pneumatosis intestinalis, portal venous gas, a fixed dilated loop, or free air; laboratory panel — full blood examination (platelet count), C-reactive protein, blood gas (metabolic acidosis), glucose and electrolytes, and blood cultures. [1]
• Treat the cause by stage: suspected NEC, NPO 3 to 7 days with observation; definite NEC (pneumatosis), NPO 7 to 10 days with antibiotics; advanced NEC or perforation, NPO 14 days or more with urgent surgical intervention (primary peritoneal drain for isolated perforation in the very small, laparotomy with resection and stoma for necrosis). [1]
• Re-advance feeds safely when the gut has recovered: standardised protocol, mother's own milk, trophic feeds then gradual advancement, check tolerance before each step. [4]

Counselling the parents

• Explain clearly that their baby's gut, which is immature because of the early birth, has become inflamed — a condition called necrotising enterocolitis — and that the team has stopped the feeds to let the bowel rest while it heals, with antibiotics and intravenous fluids for support. [2]
• Set immediate expectations: the baby will be nil by mouth for a week or more, the team will monitor closely with X-rays and blood tests, and most infants recover with medical management, though a small number need an operation if the bowel is damaged or perforated. [1]
• Be honest about the longer view: babies who recover from NEC generally do well, but those who need surgery can face a longer road — short-bowel problems and slower development — which is why the team monitors growth and development closely afterwards. [2]
• Reassure that mother's own milk is one of the best protections they can give, support them to continue expressing, invite questions, check understanding, and offer a follow-up contact with clear safety-netting on the signs to tell the team about. [3]