Problem Description
Necrotizing enterocolitis (NEC) refers to a disease process associated with the gastrointestinal (GI) tract occurring in neonates. The disease process results in the inflammation and bacterial infection of the inner lining of the bowel. Bin-Nun, Bromiker, Wilschanski, Kaplan, Rudensky, & Hammerman (2005) take note of the fact that necrotizing enterocolitis is one of the leading causes of morbidity and mortality among premature neonates regardless of the advancements in neonatal care. Approximately 90-95% of the cases of necrotizing enterocolitis occur among children born before 36 weeks with 5-10% of these cases resulting in admission in newborn intensive care units. Thus, this seeks to highlight the extent to which this becomes a problem of concern in neonatal care. Additionally, this emphasizes the importance of having to find practical solutions that would help in the management of the condition with the intention of reducing the possibility of morbidity and mortality within this population.
Literature Review
A review of the literature on the topic seeks to expose the extent to which necrotizing enterocolitis ought to be considered as a critical problem of concern in the healthcare sector. Bin-Nun, Bromiker, Wilschanski, Kaplan, Rudensky, & Hammerman (2005) reflect on the fact that although more and more preterm babies, born before maturity, are surviving due to an advanced case, necrotizing enterocolitis remains as one of the leading causes of death for this population. It can be noted that a significant number of the neonates suffering from NEC are born prematurely resulting from the fact that they tend to have low immune systems protecting them from any bacterial infections. The mortality rate among neonates with NEC is between 15% and 30% depending on early diagnosis and effective management of the condition (Battersby, Longford, Mandalia, Costeloe, Modi, & Enterocolitis, 2017).
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Samuels, van de Graaf, de Jonge, Reiss, & Vermeulen (2017) also point out that another risk factor contributing to the occurrence of necrotizing enterocolitis among neonates is low birth weight (<1500g). In these neonates, the likely outcome is that they tend to experience an alteration in normal bacterial colonization occurring within the gastrointestinal (GI) tract. Thus, this results in a situation where the bacteria tend to cause infections within the lining of the bowel wall thereby creating a high risk of NEC. On the other hand, mucosal damage associated with free radical production may also act as a contributing factor for NEC when dealing with children with low birth weight. The general outcome is that the bacteria in the bowel contribute to the inflammation of the bowel wall. Lenfestey, de la Cruz, & Neu (2018) argue that having a clear understanding of the risk factors, especially when dealing with premature or preterm neonates, as well as, low birth weight neonates may play a critical role in the effective management of the condition.
Some of the essential clinical manifestations associated with necrotizing enterocolitis include apnoea, desaturations, and temperature instabilities among the neonates (Lim, Golden, & Ford, 2015). Additionally, bloody stools and abdominal tenderness may also act as essential symptoms for the condition among neonates (Lim, Golden, & Ford, 2015). Advancements in antenatal and neonatal care have played a key role towards ensuring that survival rate among neonates suffering from NEC increases significantly. Elgin, Kern, & McElroy (2016) argue that the advancements in neonatal and antenatal care have been of great value towards ensuring that more than 75% of the high-risk neonates suffering from NEC survive. However, one of the critical issues to take note of is the fact that some of the neonates do not respond positively to medical management of the condition, which, in turn, increases the risk of morbidity and mortality significantly.
Solution Description
In dealing with necrotizing enterocolitis among neonates, it is essential to reflect on some of the possible solutions that would be effective in the management of the condition. However, Elgin, Kern, & McElroy (2016) take note of the fact that most of the solutions adopted reflect more on slowing the progression of the condition, thus, paving the way for positive health outcomes. The essential first solution to consider is medical management. Medical management reflects more on the intake of antibacterial medication within a given period while ensuring that the neonates go through regular abdominal radiographs (Velazco et al., 2018). Some of the common medications used in managing the condition include Ampicillin, used in managing gram-positive enteric organisms, Gentamicin, used for gram-negative enteric organisms, and Metronidazole, used for anaerobic enteric organisms. The selection of the medication to use depends wholly on the type of bacterial organisms affecting neonates considering that these organisms may vary from one newborn to another due to various factors (Velazco et al., 2018).
If neonates do not improve significantly even after having to go through medical management, pediatricians may have the option of using surgical management as the alternative solution in dealing with the condition. Kastenberg, Lee, Profit, Gould, & Sylvester (2015) argue that surgical management is an approach in which neonates are expected to go through surgery with between 20% and 60% of the NEC cases in neonates being treated through surgery. In a majority of the neonates, the most effective approach is the laparotomy in which an ostomy is created within the bowel for purposes of preventing progression of the bacterial infection. In some cases, a second laparotomy may be necessary, which may take place between 24 and 48 hours after the first laparotomy has been conducted on the neonate (Kastenberg, Lee, Profit, Gould, & Sylvester, 2015).
Change Model
The change model associated with the effective management of necrotizing enterocolitis in the neonatal population involves having to focus on the adoption of a strategic approach from which to reduce the mortality rate due to NEC. The model seeks to reflect on ensuring that preterm neonates born before 36 weeks, as well as, those born with low birth weights are taken through a series of tests to determine their risk of NEC. The laboratory tests may focus on examining the overall structure of bacterial colonization occurring within the bowel to decide whether or not it is happening at a reasonable rate. Additionally, this will also focus on ensuring that the neonates are exposed to abdominal radiographs as a way of examining the inner lining of the small and large intestines. This is a useful change since a majority of the preterm neonates or those born with low birth weights are not exposed to these tests for purposes of determining the possibility of necrotizing enterocolitis.
On the other hand, the change model may focus on the adoption of two management approaches for this particular condition among neonates. These are the medical and surgical management approaches. The adoption of these approaches may act as effective ways from which to deal with the number of cases identified among neonates. Additionally, these approaches will play a critical role towards ensuring that neonates are able to deal with the bacterial infections occurring within their bowel effectively. The implementation of this change model is essential, as it seeks to ensure that indeed the survival rate for neonates suffering from NEC increases significantly.
Implementation Plan
The implementation of the change model, as has been described in the previous section, will focus on two key phases. The first phase of the implementation process will be on the training of the pediatric staff dealing with neonates. The purpose of the exercise is to ensure that they have a clear understanding of the extent to which this remains as a critical condition contributing to high morbidity and mortality rates. The training will provide the staff with adequate information on how to engage in testing of the neonates as a way of ensuring that they can identify specific neonates were suffering from necrotizing enterocolitis. The second phase will be the actualization of the change model, which will focus on examining neonates within the neonatal department with the aim of ensuring that they can identify any neonates that may suffer from necrotizing enterocolitis.
Evaluation
The evaluation approach will focus on the analysis of documentation associated with neonates to determine the exact number of neonates that have gone through testing for necrotizing enterocolitis, as well as, evaluating the number of neonates diagnosed with the condition. Evaluation will focus on ensuring that the neonatal population can overcome the high morbidity and mortality rates associated with NEC based on practical approaches taken by the staff handling this population. The effectiveness of the change model would depend wholly on whether the health facility would be able to engage in effective management approaches touching on necrotizing enterocolitis. Additionally, this will also be determined by the survival rate when dealing with preterm or premature neonates, as well as, those born with low birth weights.
References
Battersby, C., Longford, N., Mandalia, S., Costeloe, K., Modi, N., & Enterocolitis, U. N. C. N. (2017). Incidence and enteral feed antecedents of severe neonatal necrotizing enterocolitis across neonatal networks in England, 2012–13: a whole-population surveillance study. The Lancet Gastroenterology & Hepatology , 2 (1), 43-51. https://www.sciencedirect.com/science/article/pii/S2468125316301170
Bin-Nun, A., Bromiker, R., Wilschanski, M., Kaplan, M., Rudensky, B., Caplan, M., & Hammerman, C. (2005). Oral probiotics prevent necrotizing enterocolitis in very low birth weight neonates. The Journal of Pediatrics , 147 (2), 192-196. https://www.sciencedirect.com/science/article/pii/S0022347605003124
Elgin, T. G., Kern, S. L., & McElroy, S. J. (2016). Development of the neonatal intestinal microbiome and its association with necrotizing enterocolitis. Clinical Therapeutics , 38 (4), 706-715. https://www.sciencedirect.com/science/article/pii/S0149291816000187
Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., & Sylvester, K. G. (2015). Effect of deregionalized care on mortality in very-low-birth-weight infants with necrotizing enterocolitis. JAMA Pediatrics , 169 (1), 26-32. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1921651
Lenfestey, M. W., de la Cruz, D., & Neu, J. (2018). Food Protein-Induced Enterocolitis Instead of Necrotizing Enterocolitis? A Neonatal Intensive Care Unit Case Series. The Journal of Pediatrics, 14 (2), 126-138. https://www.sciencedirect.com/science/article/pii/S0022347618306024
Lim, J. C., Golden, J. M., & Ford, H. R. (2015). Pathogenesis of neonatal necrotizing enterocolitis. Pediatric surgery international , 31 (6), 509-518. https://link.springer.com/article/10.1007/s00383-015-3697-9
Samuels, N., van de Graaf, R. A., de Jonge, R. C., Reiss, I. K., & Vermeulen, M. J. (2017). Risk factors for necrotizing enterocolitis in neonates: a systematic review of prognostic studies. BMC Pediatrics , 17 (1), 105-112. https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-017-0847-3
Velazco, C. S., Fullerton, B. S., Hong, C. R., Morrow, K. A., Edwards, E. M., Soll, R. F., ... & Modi, B. P. (2018). Morbidity and mortality among “big” babies who develop necrotizing enterocolitis: A prospective multicenter cohort analysis. Journal of pediatric surgery , 53 (1), 108-112. https://www.sciencedirect.com/science/article/pii/S0022346817306504
