Infant born at 32 weeks gestation, weight 1.776 kg. Initiated on expressed breast milk fortified to 24 kcal/oz with sHPCL HMF via OG tube every 3 hours, along with IV dextrose and calcium supplementation.
Target fluid orders: 140 mL/kg/day providing ~89 kcal/kg/day.
Within the first week, feeds were advanced to 90 mL/kg/day with justification being apparent tolerance (voiding, stooling, weight gain) and correction of elevated sodium.
On Day 5 of life, the infant developed abdominal distension, bloody OG aspirates, metabolic acidosis, hypoxia. Imaging confirmed pneumatosis intestinalis and portal venous gas, diagnosis of necrotizing enterocolitis.
Progression to intestinal perforation required emergent laparotomy, silo placement, and subsequent multiple resections of necrotic bowel.
Infant remains hospitalized over four months later, on continuous TPN due to short gut syndrome and intestinal failure.
Standard of Care concerns:
-The infant was advanced to full fortified feeds (24 kcal/oz) within the first 5 days of life?
-Fortification was initiated early, before showing tolerance to unfortified breast milk?
-High-calorie fortifier: used from the outset, increasing osmotic stress on the premature gut?
Preliminary research says standard NICU protocols typically recommend a more gradual feed advancement of 15–25 mL/kg/day with fortifier added only after reaching 80–100 mL/kg/day of tolerated breast milk.
Or was this acceptable plan based on the prematurity and is a known complication?
Thank you for your time and questions/addt'l info available
Files:
Q: I assume there’s no cardio, respiratory distress, apnea or risk factors for infection.
A: Correct
Q: Were there the paternal inspectors for potential ischemia in utero, such as preeclampsia and or placenta or history of magnesium use during labor
A: None documented
Q: Perinatal risk factors, placenta abruptia
A: None documented
Q: Did this particular Minon test care unit have a feeding guideline for 32 weeks gestation preterm infants and if they did, did they follow that guideline
A: I am not 100% sure, but I would assume so. It does a significant amount of deliveries daily.
Q: Particular NICU
A: See above
Do you believe there might have been medical error?
It is well established with many clinical studies that too rapid advancement of feeds in a premature baby, and not responding to any sign of intolerance to feeds, is very likely to lead to NEC. This was the case in this baby.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
NEC does not develop in babies who are not fed. So feeding is a prerequisite fot the development of NEC. If feeding is not stopped, or advancement of feeds slowed down appropriately, when a baby shows signs of intolerance, it is very likely that the baby will develop NEC.
What makes you a good expert for this case?
I am neonatologist with close to 40 years of clinical experience. I have managed many cases of NEC. I have served as an expert on many similar cases. Please refer to my biosketch.
How often do you encounter cases similar to this one in your practice?
In our academic center, we avert serious cases of NEC by responding to the frst sign of threatened NEC. We do get severe cases transferred to us from other centers.
Do you believe there might have been medical error?
While a gradual feeding schedule is often utilized, there is no good evidence to support this. Recently there have been studies showing that a more rapid advancement is well tolerated by preterm infants. As far as fortification is concerned, while many do not fortify until a volume of 80-100 ml/kg there are recent studies suggesting it is safe to do so at much lower volumes at 40 ml/kg. Indeed, when premature formulas were widely used, 24 calorie formulas were the feeding of choice in many NICUs, although many began with more dilute 1/2 strength.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It has not been demonstrated that a faster rate of feeding or earlier fortification of human milkvis associated with necrotizing enterocolitis.
What makes you a good expert for this case?
I am a board certified neonatologist with over 40 years of clinical experience and have directed two Level 3 NICUs.
How often do you encounter cases similar to this one in your practice?
I have seen NEC develop in infants at 32 weeks on occasion. The incidence is really more a concern in smaller infants. Was this a small for gestational age infant? Infant of a diabetic mom? Other risk factors?
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