Poor feeding and feeding intolerance in the neonate — formative SAQs

SAQ 1 (10)

A 12-day-old infant born at 27 weeks' gestation, weighing 920 g, is on advancing expressed breast milk feeds at 120 mL/kg/day. The nurse reports that the pre-feed gastric residual is now larger than the feed volume and is bile-stained, the abdomen looks fuller, and the infant has had three apnoeic spells requiring stimulation. ^{[1] [3]}

1. Interpret these findings and state the most likely diagnosis to exclude. (3) ^[1]
2. Outline your immediate management. (4) ^[3]
3. Describe the investigation that confirms the diagnosis and the findings you seek. (3) ^[3]

Model answer

1. These findings are feeding intolerance with systemic signs in an extremely preterm infant — necrotising enterocolitis until proven otherwise. The increasing and bile-stained residual, abdominal distension, and new apnoea are the systemic and gastrointestinal signs of early NEC. A bilious residual also raises a surgical obstruction, but in this preterm the context makes NEC the leading diagnosis to exclude. ^[1]
2. Stop feeds (nil by mouth), pass a large-bore orogastric or nasogastric tube on free drainage to decompress the gut, establish intravenous access, resuscitate with 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. Escalate to the neonatal team and, in a rural setting, activate retrieval. ^[3]
3. A plain abdominal radiograph (anteroposterior, plus a left-lateral-decubitus or cross-table-lateral view) confirms NEC when it shows pneumatosis intestinalis (gas in the bowel wall — the hallmark), portal venous gas, or a persistently dilated loop. Free intra-abdominal gas indicates perforation. The laboratory panel (full blood examination for thrombocytopenia, C-reactive protein, blood gas for metabolic acidosis, glucose, blood cultures) grades the severity. ^[3]