Episode 10 features Dr. Sergio Golombek, a Professor of Pediatrics and Clinical Public Health at the New York Medical College and an Attending Neonatologist at The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center (Valhalla, NY). During the episode, Dr. Golombek discusses:
* How researchers are refining the definition of NEC, and other prematurity-associated complications that may currently fall under that umbrella term,
* The evolution in prevention and diagnosis strategies of NEC,
* The colonization of the intestinal microbiome, and the role it can play in immune system regulation, and inflammatory diseases like NEC,
* Additional research trends in NEC, including his unit’s research of granulocyte-colony stimulating factor (G-CSF) in the prevention and treatment of NEC, and
* The importance of individualized patient care in the NICU.
Copyright © 2015 The Morgan Leary Vaughan Fund, Inc. This episode was produced in part by the TeacherCast Educational Broadcasting Network.
STEPHANIE VAUGHAN, HOST: Welcome to Episode 10 of Speaking of NEC—a free, audio podcast series about Necrotizing Enterocolitis.
Produced by The Morgan Leary Vaughan Fund, and funded by The Petit Family Foundation, Speaking of NEC is a series of one-on-one conversations with relevant NEC experts—neonatologists, clinicians and researchers—that highlights current prevention, diagnosis, and treatment strategies for NEC, and the search for a cure.
For more information about this podcast series or The Morgan Leary Vaughan Fund, visit our website at morgansfund.org.
Hello, my name is Stephanie Vaughan. Welcome to the show. I’m the Co-founder and President of The Morgan Leary Vaughan Fund.
Today, my guest will be Dr. Sergio Golombek, a Professor of Pediatrics and Clinical Public Health at the New York Medical College and an Attending Neonatologist at The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center in Valhalla, NY.
Dr. Golombek will share with me today a comprehensive overview of NEC, and current research trends. During our conversation, he will discuss in varying degrees:
- Signs and symptoms,
- Defining NEC,
- The microbiome,
- Inflammatory factors,
- Diagnosis, and
- Current areas of research
He will also discuss the continuing evolution of individualization of patient care in the NICU, and some of the notable changes that he has seen take place in the care of premature infants over the course of his 30-year career.
With that in mind, let me introduce my guest today.
Hi, I’m with Dr. Golombek from Westchester Medical Center. Hi, Doctor, how are you?
SERGIO GOLOMBEK, GUEST: Fine, thank you, how are you?
STEPHANIE: Good. Let me let you introduce yourself and give a little bit of background. And then we can get into your experience with NEC, and some of the hotter topics off…some of the research trends.
DR. GOLOMBEK: Okay, sure, thank you. I am a professor of pediatrics and clinical public health at New York Medical College and I’m an attending Neonatologist at The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center. I’ve been there for 16 years, before the hospital was built. Our group moved from Stonybrook for the idea of this children’s hospital. We built a new place, which is fantastic.
STEPHANIE: Excellent. So, tell me a little bit about your experience specifically with NEC.
DR. GOLOMBEK: Well, as an attending neonatologist, working at a very high level, and high acuity, and high intensity NICU, a significant proportion of our babies have N-E-C. Some of them because they develop it while they are in the unit, many of them are transferred to our center to get the technology that is available where I work, have the surgical consults, treatment, and whatever else is needed, we are lucky enough and fortunate enough to have a center that can receive babies from acute at that area in the state of New York and many babies from many community hospitals, or even level II or IIIs, some of them are related with us, some not, would transfer babies to us when they get to the point where they’re too sick to be managed well.
STEPHANIE: And can you tell me, before we get into some of the research trends, for parents that have babies in the NICU who might not know a lot about N-E-C, or NEC, what’s the typical experience of somebody that’s going to be transferred to your high level NICU?
DR. GOLOMBEK: Well, these are babies, most of them premature that had done reasonably well in the first few days or couple of weeks of life, and one of the interesting things about N-E-C is that it’s directly related to how premature the baby is, and based on that, the timing of when N-E-C appears versus bigger babies or older babies, it appears a little bit sooner in life. So it happens that a very tiny kid is born, and he or she needs a lot of things at the beginning: it could be…or not; they could need Surfactant or not…and after the first nightmare, if you want, things get a little bit better, then phototherapy is over, and feedings are going reasonably well, and at some point, the baby decides to be distended, not direct feeds, start having residuals, occasionally they forget to breathe. And this happens about two or three weeks down the history of this baby, so it’s a pretty tough thing because when people think that, okay, now we’re over the hump, there are still things coming.
STEPHANIE: Right. Yeah, my son was diagnosed…he was born at…my twin sons were born at 29 weeks. I’m sorry, 28 weeks and one day, and he was actually diagnosed at four days old. So he was diagnosed very early, and they had just started feeds. I think it was his second feed.
DR. GOLOMBEK: Oh, okay.
STEPHANIE: And he was transferred to Yale for a surgical consult, and lost 20 percent of his small intestine.
DR. GOLOMBEK: Okay. Okay. Well, in the thick scheme of things, that’s not too bad.
STEPHANIE: Right, right. No, he’s doing very well now. Yeah, he’s doing very well.
DR. GOLOMBEK: What happens, it’s really interesting. First of all, NEC, you have suffered it, so you know pretty well it’s really one of the most serious diseases that we have in the NICU. And it’s actually the most common gastrointestinal problem that we see at least in a high level NICU. It’s supposed to affect about five, ten, eight…up to ten percent maybe of the babies that are admitted to a NICU, and still today, I’ve been doing this for many, many years and still today, it has a very significant mortality, depending on what you read: 20, 30 percent, 40 percent mortality depending on the regions, depending on the countries. The problem is not only some of the babies die, many of the babies that survive have some significant problems associated with it. Up to to certain extent of it, your son, most likely because only, quote unquote, only 20 percent of the gut…
DR. GOLOMBEK: ..is not too bad. If he still has the ileocecal valve that puts him in a different category, it’s bad enough and he has enough scars to show when he grows up.
DR. GOLOMBEK: And it’s going to take some years of nightmares from you to get over it.
DR. GOLOMBEK: But compared to other kids that could present very early or very late, some of this disease is really devastating, and the more premature the baby, the younger they are, the sicker they are, the disease can be really, really horrendous.
DR. GOLOMBEK: Basically, we get babies transferred to us where there is nothing else to do because the diagnosis is there, but there is no more gut available. In this state of technology, we’re still not ready to get to what hopefully, whenever your son becomes a physician and starts treating babies, we’ll hopefully have maybe gut transplant as a routine technique for these babies.
STEPHANIE: Right. That would be awesome. So let’s talk a little bit about, I guess prevention, and what you see in the trends for prevention.
DR. GOLOMBEK: Okay. First, let me get back a little bit. One thing that has been changing a little bit in our knowledge on the way we face these cases is that maybe not everything that we call NEC is actually NEC.
DR. GOLOMBEK: That’s also important to understand because many times, in fact, I have a baby now that we are trying to negotiate the diagnosis if you want, because some of the signs or symptoms of N-E-C are pretty much the same as any other thing that you see in a baby, so if a kid has sepsis, he or she is going to have a distended tummy and he’s probably not going to be able to tolerate the feeds. And occasionally, depending on what the exit looks like, that could be called N-E-C. It’s not a typical, classic thing associated with everything that we’ve seen in many years. And intestinal ischemia could also be called N-E-C because if you don’t have good profusion of the gut, and intestinal mucosa dies, secondly to that, you have exactly the same signs and symptoms for the baby: distended abdomen, discolored abdomen, tender abdomen, eventually even pneumatosis (intestinalis—the presence of gas in the bowel wall). So not everything that we put in that big bag really responds to the same—and I think that’s important to understand because it puts somewhat into perspective that not everything that you would do to these babies will prevent N-E-C 100 percent.
DR. GOLOMBEK: In the dark ages when I started practicing neonatology, we used to not feed babies that were sick because we thought that they were so sick that their gut was compromised to the point where it was not going to be able to tolerate any feeds, so for a week, we didn’t feed them. Of course, now we know that’s a really bad mistake because it’s sort of adding insult to injury, and on a gut that is initially nowhere profused, we don’t feed, we don’t allow normal, appropriate, good bacteria if you want to start reproducing in the gut, and then when we start feeding, of course, that gut is not ready, and then we run into trouble.
DR. GOLOMBEK: You know that well, those things before.
DR. GOLOMBEK: I think we have come a long way from that including one of the ways of preventing many of the bad things that happen to these babies, is as soon as we have these kids, we start with minimal enteral nutrition with just a little bit of breast milk if we have, or donor breast milk in our case if we don’t have mommy’s breast milk. Just giving a little bit of support, a little bit of normal flora to that gut actually gives a lot of benefit. So, that’s one of the things that you can use for prevention. The other thing that you can use is, of course, be careful and wash your hands before and after touching every baby, being sure that everything that is appropriate, that if anyone is sick when it comes to the kid, he doesn’t approach the baby because N-E-C, we know now that it’s not just a bacteria problem. It could be caused by pretty much everything that could have some impact on the baby, and that includes multiple gram-negative bacteria that normally would be there, but they start growing in an abnormal fashion. The first stages of N-E-C usually are associated with gram-positive bacteria, but also viral infections can give you N-E-C.
DR. GOLOMBEK: So anyone that is sick, as with any other baby, remember that these preemies are very immature, and that includes everything from the head to the toes, everything is immature. So every time you attack them with something they’re not prepared to defend against, they’re in trouble. That’s why they get problems with the lungs because they’re not able to breathe…because inside your tummy, your twins were breathing very low oxygen because your placenta did all the work. Once they get out, they had to adjust. Their gut was very well prepared to receive a big load of amniotic fluid, they can process it very well. NEC doesn’t happen in utero. It happens once the babies are out. We expose them to things, we expose them, one of the most common theories now is that all of the inflammatory factors that are involved in the first few days of their new life will in some manner change the way the gut reacts, change the way the gut interacts with normal flora that babies acquire, sort of normal flora, they get colonized with mommy’s flora when they get through the birth canal, but for many years, we would prevent that colonization, we would feed babies with broad spectrum antibiotics for a long time, preventing…trying to keep these babies sterile and that was really a mistake. What we need to do is keep them colonized them with the right bacteria.
STEPHANIE: Okay, so you’re talking about feedings, and the flora, and the gut. Can you talk to us a little bit about 100% human milk diet, and exclusive breastfeeding? You talked about donor milk.
DR. GOLOMBEK: Um hm. Yeah. We know now that probably the best protection for everything, not just for the gut, is breast milk. That’s how we were invented, that’s how we were designed, and throughout thousands of years, breast milk has changed and evolved into a cumulative package of many, many good things for the babies. Unfortunately, when you’re a mommy, you’re not really designed to produce gallons of milk when you deliver a preemie baby. A couple reasons are that you’re not ready. Also, you’re under stress, you’re in pain, you’ve come from a C-section, or from suffering the vaginal birth of these babies, and you’re not ready—you need a little bit of time until that fits into place. Although, if you coach the mothers perfectly, they can actually get even a little bit of colostrum on the first day for sure, but by the second day of life. So the properties of breast milk are such that you can actually make a good interaction between something called toll-like receptors, which are sort of defense mechanisms that we have in our gut, and interaction against pathogenic bacteria, the bacteria that would actually cause harm to the gut. You can start selecting what actually keeps growing in the gut, that again should not be sterile, you colonize it with appropriate flora. If you breastfeed, you get a very different flora. The bacterias are called enterobacteria (gram-negative bacteria) or bifidobacteria (gram-positive bacteria), which are the most common one if you breastfeed versus if you formula feed a baby, they usually get just enterobacteria, occasionally some gram negative. So the selection is very different. And that sets the stage from day zero, as soon as the babies are out, of what gets into the gut. It would be processed. It would be going through the gut mucosa. It’s going to be absorbed, and in the defense mechanisms or the immune system of the baby, it’s going to start facing different bacteria and different processes are going to get started from day zero that actually have an impact for the whole life of this baby. It’s actually fascinating. We are learning more and more that this microbiome, or…life that we have carrying inside of us which actually, we have many more bacteria than cells in our body that are living inside of us, so we’d better be careful for the right ones to be colonized with, and that actually is the stage that is set as soon as the baby comes out, and with the first things that we do: breast milk versus formula, one antibiotic versus the other, prolonged antibiotics versus not. Maybe without feeding them versus feeding them appropriately, all that to set the stage because the body is going to recognize some of the things as normal and some of the things as abnormal. And a lot of diseases down the road will be associated with what we do in the first crucial days, week of life.
STEPHANIE: Interesting. Just as an aside, can you talk to me a little bit about what those diseases might be? Are they at all related to children that have had NEC versus not having NEC?
DR. GOLOMBEK: No. No, no.
STEPHANIE: Or just in general?
DR. GOLOMBEK: The research in the past very few years, primarily in people that are very interested in microbiome, and how we encounter different bacteria, and how we colonize our gut, based on an immature gut or even on a not immature gut, that really sets the stage to the way we react to feedings down the road, the way we react to allergies, the way you have or not asthma, the way or not you can…become allergic to something, or even rheumatic diseases. Everything seems to be related in some way on how you modulate your immune system starting very, very early. Of course, the quid pro quo is how much of this is genetics, and you inherit it—and it really doesn’t matter if I give you formula or I give you breast milk, and how much is epigenetics—so you have a predisposition, and on top of that, you have someone that is altering the way you will react and down the road, the cascade starts very early, and then that’s the way you react. So we still don’t have the final answer, but it seems that the more natural things initially, and the less involvement from us…an ivory tower deciding this is what you want, baby. So you’re not going to eat, you’re going to be on just water and sugar, and maybe I’ll give you some protein. That was a mistake. So now we have changed with the idea that the best nutrition that we can offer, enteral or parenteral, is much better for these babies. We give them enough protein. We like to make them build all of the walls that they need. The gut, the lung, the brain, the eyes—pretty much everywhere—they need enough calories, but they need the right proportion of things, which we’re slowly starting to understand. Of course the best proportion is what’s already invented, which is breast milk.
DR. GOLOMBEK: For preemies it doesn’t work that well, as you know. You get also very stressed out if I tell you that I start with 20 mLs (milliliters) per kilo (kilogram) today, and your baby is probably 1200 grams (2 pounds 10.3 ounces) or something like that, and then, okay, yeah, sure, what’s the big deal? That’s about four or five teaspoons that you want, I’ll give it to you. Tomorrow, I’m going to advance ten more, and then a little bit more, and at some point it’s like hey, hey, come on.
DR. GOLOMBEK: I’m doing everything I can, I’m doing kangaroo care, I’m pumping, but I need to sleep, I need to rest.
DR. GOLOMBEK: And by the way, the same hormone that makes your breast produce milk will make your uterus contract so you have cramps, and then you feel more miserable, and it’s a sort of cycle. The advantage that we have now is we can use just a little bit of your breast milk, and either fortify it with commercially available products that are actually very, very good, or there are more and more donor milk banks. In the state of New York, we actually don’t have…We actually have one that we just created, one of my colleagues Dr. Boriana Parvez opened a donor milk bank and is in the process of opening, finishing all of the preparations at our hospital. Before we had this, because we had bought into the idea that breast milk is the best thing for babies, we were buying breast milk from donor [milk] banks in North Carolina. They’re good, but expensive…
DR. GOLOMBEK: But of course, if you titrate or you balance, how much would be a vial of milk? Which it’s actually really very expensive compared to a carton, or a gallon of milk, in the supermarket.
DR. GOLOMBEK: And the benefits that you can get including no surgery, no short guts, no prolonged TPN, I think it’s the right decision. While we were able to get donor milk, we started using Prolacta, which is a commercially available product made in a factory that looks like science fiction if you visit it.
STEPHANIE: I actually have! I’ve actually been out there, yeah.
DR. GOLOMBEK: They’re amazing. It’s in the City of Industry in California. It’s an amazing place. I’ve visited there twice. It’s incredible when you get all of the explanations on how much in depth they go to get the best product they can. Yes, it’s a very expensive product, but it works, and it works very well. They have a wide variety of different flavors, and concentrations, and things that you can do with the product, but it’s really great, it’s really great, and their idea was really the right one: produce it, but let’s be sure that whatever we offer as a product is safe.
DR. GOLOMBEK: It’s appropriate, and every label really says what this product that you’re going to give to the baby has. So we liked the idea at the regional center, and we invested a lot of money because we met with…and said listen, we have about 110 or 120 babies less than 1000 grams (2 pounds 3.2 ounces) per year, admitted to our unit. Our mortality rate is low, but we still have trouble with morbidity, so help us.
DR. GOLOMBEK: We have to invest, we have fantastic physicians, excellent nurses, great ventilators. We have access to pretty much everything that we want. Now we need something that is very simple, but it’s expensive. So…the money, and that was to buy Prolacta.
STEPHANIE: Right, right.
DR. GOLOMBEK: And fortunately, they said yes because they really understood that it wasn’t a joke, this was a real problem, and we needed to feed these babies to make them grow in the right way, not to make them grow fat, full of water, full of fat and have problems with their sugars and things like that. It will give them enough protein, fat, and sugars, but in the right proportion.
DR. GOLOMBEK: And it worked. We are really very happy with it. I think it’s the right philosophy.
STEPHANIE: Yeah, no, I was very impressed with Prolacta, and we took the tour, and if I knew then what I know now, five years ago when we had our twins, it [would be] definitely well worth the expense I think.
DR. GOLOMBEK: At that point, they were just starting…
DR. GOLOMBEK: ..and it was tough because they also thought that people would get to this bandwagon that said, oh, give me five barrels of it. It didn’t work like that, it took a little bit of time for people to understand that it’s actually an appropriate product, and how to use it was also difficult, because you can’t just give it. You have to understand what you’re doing, what you’re giving, supplementing breast milk is one thing, if you’re using it as a replacement, it’s totally different. With experience, we’re very comfortable now. We still get consent from mother, and we discuss with the family why we think that this is appropriate recommendation, and why it would help the baby while we’re still working, we’re using breast milk, but I don’t want to stress you out telling you that now your baby needs 17 and a half mLs and you’re only giving me 15! Bad mother! That’s not good!
STEPHANIE: Right, right.
DR. GOLOMBEK: So it’s the power that we have, occasionally we don’t really pay enough attention to it. I think we miss, occasionally, the idea that it’s stressful to have a baby in the NICU, no matter how nice we think we are, or how much we smile, it’s still very tough. You drive every day to go and see your baby, and on top of that, you have good news on one day and bad news the next day, and you are very happy one day, and then all of a sudden you get a storm because the baby has a PDA and needs to be treated, or the baby has N-E-C, or baby has ADH, and we add on top of all of that, oh, by the way, are you pumping?
DR. GOLOMBEK: It’s tough. It’s tough. I think that now, lots of people understand that we don’t disrupt the normal processes, and we allow the babies to adapt, things go better, but it’s a slow process. Because most of these babies are born for some reason. Granted, many times we don’t know why, but they are born…
DR. GOLOMBEK:..and they need to readjust to something that they were really not prepared. So what we need to do is try to prevent complications, and be sure that they are comfortable, and that we try to sort of follow whatever processes we think are supposed to be in place without disrupting them. We know that there are some things that will be either prevented or treated, but some of the things cannot. For example, if the mother has Chorioamnionitis—that’s inflammation of the placenta, that will start a huge inflammatory cascade that could affect the mother up to a certain point because she could have fever, but can also, some of those factors can pass to the baby, and some of the multiple problems from those inflammatory factors would be N-E-C…ROP (Retinopathy of Prematurity) is another one. Maybe Patent Ductus [Arteriosus} is another one. So if we can prevent some things, we’ll do it, but by the time we get our hands on the baby, he or she has already gone through multiple problems, some of them are known, some of them we sort of think we know, and we need to try to prevent further problems. We need to try to prevent oxygen toxicity. We used to give these kids 100% oxygen, which is very, very toxic at every piece of this baby’s body, including the gut. They were worried about N-E-C, but it happens to every other epithelial layer, and I think we need to stop sort of commanding things and follow babies and see. You know, your babies are 5-year-olds?
DR. GOLOMBEK: So at that point, we were starting to move away from ventilating every baby, and allowing something called non-invasive ventilation. So, we sort of follow the baby, and if they’re able to breathe by themselves, we help them, but we don’t command what they do. Very different than when I started doing this in the 80s, where every baby was paralyzed, every baby was on a ventilator that was not synchronized that would deliver 40 breaths a minute, and a pressure of 20/4, and 100 percent. Every single baby in the unit was like that. Fortunately, 30-something years later, we are nicer. It’s better technology, also. The machines that we used were horrendous. So now we know a little bit better what to do, how to do it, but we can help babies very differently. We know much better how to read the initial clinical signs, rather than waiting, or sort of dismissing that ah, well, okay, it’s just a bit of residual, that’s fine, let’s keep going. We have better technology on the laboratory perspective, we can do better CBCs. Other labs like CRP (C-reactive protein) and other inflammatory markers could be measured and compared, four, six, eight, twelve hours, we can look at x-rays better in the computer where you can change the colors, you can change the shades, you can understand things a little bit better. And I think we are slowly starting to tease out better the idea that what we used to lump as one disease may be different processes in different babies…helping because we’re not feeding everyone with 14 days of multiple antibiotics, and not feeding them, or taking them to surgery which is what [indiscernible] at a certain point. As soon as these babies were diagnosed, immediately they were rushed [indiscernible] opened and it was not really very good, in fact, at some point, we just took the babies to the OR, the surgeons would open, see what they thought was okay, close, and then open two, three days later, they would do the same area, and if the area was dead, they would just get rid of that part, but now we are a bit more conservative.
DR. GOLOMBEK: Including some surgeons will just put a drainage rather than doing a laparoscopic procedure or opening the baby, and the jury is still out which is the best procedure, but we’re trying to follow the babies rather than deciding for them.
DR. GOLOMBEK: So, I think quite a bit more humane.
STEPHANIE: Great. So is there anything else, sort of in the up and coming research, or new areas of interest that you would like to touch upon?
DR. GOLOMBEK: Specifically on N-E-C, there are a lot of things that are still being argued, starting by the diagnosis and defining what it is. There are interesting research being done in animals—rats or rabbits, depending on who’s doing the research, where they are trying to feed specific things, or trying to change the microbiome, specifically putting better bacteria, giving probiotics, and see if that makes…the gut a little bit better. The research [indiscernible] from early diagnosis and see if we can get some signs, even before the baby starts being distended or having a lot of problems, to well, can we maybe give probiotics. And that has been out in Apple or Google for a long time. It seems to be the best thing since sliced bread, and as many things in medicine, it’s not magic, and yes, some probiotics seem to be okay. We don’t know which ones are really okay. The studies that have been done showing a lot of benefit have been done in Europe, and the probiotics that are used in Europe in this research in babies are not available in the US. So it’s a little bit difficult to jump over the pond and say we should do this for every baby. We did research in our unit using two of the different strains of probiotics. It seemed to work, at least we were looking at feeding these babies after they had N-E-C, and they had some feeding intolerance, so what we did was giving them different formulas and adding probiotics, and in fact, adding those probiotics seemed to work well, but I don’t think that that’s the end of the story, because we still don’t know…the perfect dose, some of the babies can get sick, and in fact, there were a couple of kids in the U.S. that got sick from probiotics. We don’t have the final answer yet.
DR. GOLOMBEK: We need to take a little bit what could or could not be done, and then at different points either before, during, or immediately after the diagnosis, we have been trying different things. In our unit, we did some research with human [granulocyte] colony-stimulating factor, G-CSF, and these factors actually push the bone marrow to make more granulocytes, or white cells, that would be defending against foreign bodies, and it seems that if you give it early enough, you actually stimulate the normal defenses in the body, and if the baby is able to catch up quick enough, white cells, our results have been a little bit better than not giving them. Again, something, that in the future, would be part of a lot of things that we do. Of course, the feeding, giving antibiotics, but if we allow some more defenses…
DR. GOLOMBEK: [indiscernible], it sort of makes sense. If that would be the final answer, I don’t know, there are other complications giving it. But it seems that giving this makes a lot of changes in the body [indiscernible] between many of the properties that G-CSF has, it’s an anti-TNF alpha. An anti-TNF alpha is one of the most potent inflammatory factors that are released every time you get a disease like N-E-C or many others, that’s for example. So you are able to make more white cells to protect you, and for the same price, it’s something that decreases inflammation, it seems to be logical.
DR. GOLOMBEK: But we need a lot of research to prove that this is sort of the final answer, and everyone will have a cookie-cutter approach, and if you get NEC, you just press one button and five pills come, and all medications come in a robot, and okay, that’s it!
STEPHANIE: That would be lovely!
DR. GOLOMBEK: I don’t know. I still like the art of medicine.
DR. GOLOMBEK: I prefer to look at the baby and think what this particular baby at this precise time has, rather than working by guidelines that insurance company says okay, this is what you need to do.
STEPHANIE: Right, right. No, and that seems to be the way, as you were saying, that things seem to be going is more patient-specific treatment.
DR. GOLOMBEK: Yeah, exactly. I think that we’re tailoring the treatment for this specific baby has, including the fact that not everyone needs the same combination of antibiotics, because depending on why this baby developed N-E-C, depending on the age of the baby, depending on what we were feeding before it, depending on what we think the etiology is. If it started as sepsis because, I don’t know, the baby has a central line and then it was normal skin flora that got in, and secondary to sepsis, the baby has N-E-C, the coverage that we need to go at is different. So we don’t give the same for everyone.
DR. GOLOMBEK: Maybe this baby today needs this specific things, and we’ll keep antibiotics for a pre-determined amount of days, not everyone gets seven or ten or fifteen.
STEPHANIE: Yeah, that definitely seems to be the trend in treating most things I think nowadays.
DR. GOLOMBEK: We try. We try because I think that that’s more appropriate. We know from studies, not in babies, but from bigger kids or adults that at some point, based on what your genetic message is, although now it’s still jokes and cartoons, but the reality is at some point based on the genetic message, I will tell you that for this specific infection, you, person A versus person B, will need this dose of antibiotics because this is enough, if I give you the dose that person B needs, you can be toxic…or not need it. And that is a very stabled combination of your own genetics plus all of the epigenetics that were in conference when you are born, to going to the NICU, to going to school. And then based on what you encounter, it will respond very differently to enough, and I doubt that both of your kids get the same cold at the same time.
STEPHANIE: No, usually one gets it first, and then whoever gets it second is usually worse.
DR. GOLOMBEK: Yeah, so, and the way they react is different, because they are different human beings. So the same virus, the same viral load if you want, they have different reactions depending on how you are as a person. We react differently to different stimuli. We react differently to different jokes, different food, different drinks. So it’s the same with an infection. If it affects you to the point where you need to treat, but treat specifically for you as a person, not while everyone else gets the same.
STEPHANIE: Well, this was a really great conversation, I really appreciate you talking to me and I think you gave a lot of good insight, and a lot of insight from a different perspective that we haven’t heard. And, I think that tailoring the needs to the patient is definitely good on all fronts. So, I think that’s great.
DR. GOLOMBEK: Awesome. Very good. Well, I’m glad that you like it. If you want to keep talking at some other point, you know how to find me.
STEPHANIE: Great. Thank you so much. I really appreciate it.
DR. GOLOMBEK: Thank you, have a good night.
STEPHANIE: You too, bye, bye.
In closing, I’d like to share a few thoughts about today’s conversation with Dr. Golombek.
There is a history of colorectal cancer on my mother’s side of the family. Both my maternal grandfather and uncle had colon cancer. My grandfather survived. Sadly, my uncle did not. He passed away from complications at the age of 56.
So when Morgan underwent emergency surgery for NEC at 4 days old, my family’s history brought me a small measure of comfort amidst the chaos. I had a previous experience with the same surgical procedure that Morgan would undergo. And if only peripherally, I understood that an ostomy could be successfully reversed like in my grandfather’s case. And perhaps, it even provided me the awareness that as critical as the situation was that Morgan faced, it was survivable.
Almost immediately afterward, what I may have viewed as a positive started to give me pause. I thought about Morgan’s future. What could he expect at 5 years old? At 10 years old? At 25 years old? Would this bout with NEC increase his chances of developing cancer, or another gastrointestinal disease, later in life?
And as I began to learn more about NEC, my thoughts returned to family history. Did our family history play a role in Morgan’s development of NEC? Was he predisposed to this disease?
Morgan presented with an atypical case of NEC. And based on the preventative strategies in place at the time of his birth in 2010, and those currently recommended, I don’t believe that anything more, or different, could have been done that would have resulted in him not developing NEC.
However, I do believe that through increased advocacy and support of research that someday very soon we will have a clear understanding of what causes NEC, and a precise method to eradicate this potentially devastating disease.
Show your support for our smallest and most fragile babies, those who have the greatest risk for developing NEC. Show your support for continued research in NEC. And join our effort to raise awareness about, and funds for research in NEC by making a donation to Morgan’s Fund at morgansfund.org/donate.
If you’ve had a personal experience with NEC and would like to share your story, or have a question or topic that you’d like to hear addressed on our show, e-mail us at firstname.lastname@example.org. We’d love to hear from you!
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