Necrotizing Enterocolitis

Aetiology
NEC is a multifactorial condition and the exact cause is unknown. Damage to the intestinal mucosa
can occur due to vascular insults, toxin exposure, infection and genetic factors.

This damage allows pathogenic colonisation of normal commensal bacteria. However, some

outbreaks of NEC have been isolated to a pathogenic organism, such as Escherichia coil.3

Risk factors
85% of NEC cases occur in infants who are premature, or with a low birth weight.3

Other risk factors include:

 Congenital heart disease

 Antibiotic treatment lasting longer than 10 days
 Enteral feeding
 Use of cow’s milk formula (breastfeeding is protective against NEC)

Clinical features
History
NEC usually presents within the first two weeks of life.

Typical symptoms of NEC include:4

 A new feed intolerance

 Vomiting (which may be bilious)
  Haematochezia (fresh blood in the stools)

Other important areas to cover in the history include:

 Feeding history: infants with NEC often have a new onset feed intolerance. Ask about rate
of feeding, volume taken, vomiting after food, any changes in food (e.g. from breast to
bottle and changes in formula).3
 Bowel movements: ask about normal bowel habits. Has meconium been passed? How often
do they open their bowels? This can be quantified by the number of dirty nappies in a day.
 Past medical history: although this may be limited in an infant, it is important to cover the
known risk factors.
 Pregnancy history: it is important to take a thorough pregnancy history from the
parent/carer.
 Family history: ask about a family history of illness in the newborn period. Many neonatal
conditions, including NEC, have a genetic predisposition.

Pregnancy history
Key areas to cover in the pregnancy history include:

 Was the mother under hospital-led maternity care (and if so, why)?
 Was this a high-risk pregnancy?
 Did the mother or baby develop any problems during the pregnancy?
 Pregnancy gestation?
 Method of birth?
 Any complications with the birth (both mother and infant)?

Clinical examination
All unwell infants require a thorough clinical examination. See the Geeky Medics guide here for
further information.

Typical clinical findings in NEC include: 3

 Abdominal distension
 Reduced bowel sounds
 Palpable abdominal mass
 Visible intestinal loops
 Signs of sepsis

NICE traffic light system

The NICE traffic light system can be used to help interpret examination findings to give an indicator
of severity.5
Differential diagnoses
The clinical presentation of NEC can appear similar to several other conditions.

Table 1. Differential diagnoses of NEC.

Condition Clinical features

Can develop as a complication of NEC. NEC has a specific presentation on

abdominal X-ray.3 
Sepsis
Common causes of neonatal sepsis include group B strep infection, premature or
prolonged rupture of membranes, chorioamnionitis and maternal septicaemia. 6

Intussusception occurs in infants aged between 3 months and 3 years; it is rare in

Intussusception
infants. NEC tends to occur in the first 2 weeks of life. 7

Volvulus An important differential for the acute abdomen in infancy. 3

Hirschsprung’s Hirschsprung’s can cause failure to pass meconium in the first 48 hours of life,
disease NEC does not cause this.8

Investigations
Laboratory investigations
 Baseline blood tests (FBC, CRP): CRP may be raised and there may be thrombocytopenia
and neutropenia.
  Blood cultures: non-specific in NEC and are commonly reported as negative. However, if a
bacterial, viral or fungal agent is isolated this can be useful for guiding treatment. 9
 Blood gas: may show a raised lactate or acidosis.

Imaging
 Abdominal ultrasound: ultrasound is a safe first choice of imaging due to the lack of
exposure to ionising radiation. Signs that are indicative of NEC include air in the portal
system, ascites and perforation.
 Abdominal X-ray: may show thickening of the bowel wall, dilated bowel loops filled with
gas and distended bowel.10
 If the bowel has perforated, Rigler’s sign may be visible. This occurs when both sides of the
bowel wall are visible due to the presence of gas inside the lumen and within the peritoneal
cavity.11
 Fi
gure 1. X-ray of an infant with necrotising enterocolitis.13
Management
Neonates with suspected NEC require urgent review by a paediatric surgeon.

Medical management
Principles of medical management for NEC include:4

 Keep the infant nil by mouth (total parenteral nutrition may be required)
 Consider bowel decompression with a nasogastric tube
 Assess and manage sepsis
 Intravenous fluid resuscitation
 Intravenous antibiotics (broad-spectrum cover is recommended as first-line, such as
cefotaxime and metronidazole)
 Circulatory support and ventilation may be required

Surgical management
Surgical management is required in 20-50% of cases.2

According to the modified Bell’s staging criteria, the main indication for surgical intervention
is evidence of perforation. A laparotomy is carried out to remove perforated and necrotic bowel
from the abdomen.5

Complications
Approximately one in four infants who develop NEC will require surgery. Of those, a 29% post-
surgical mortality has been reported at one year. 12

General complications of NEC include:3

 Bowel perforation
 Disseminated intravascular coagulation
 Sepsis
Post-operative complications of NEC include:3

 Short bowel syndrome

 Formation of intestinal strictures
 Enterocolic fistulae
 Abscess formation