Emergent Care / Stabilization:
Initial stabilization measures should address the standard airway, breathing, and circulation (ABC). Enteral feeds should be immediately stopped and a Replogle tube placed. If apnea, respiratory distress, or hypoxia are present, intubation and mechanical ventilation may be required. Hypotension must be immediately addressed with fluid resuscitation and pressor support if needed. Transfer to a neonatal intensive care unit (NICU), if not already there, and consult pediatric surgery in severe cases of NEC or bowel perforation.

Diagnosis Overview:
Necrotizing enterocolitis (NEC) is a serious, life-threatening, acute inflammatory disease of the intestinal wall that can range in severity from intestinal mucosal damage to full-thickness intestinal wall necrosis with resultant perforation. NEC is more prevalent in premature infants, with incidence inversely related to gestational age and birth weight. While NEC is most common in infants weighing less than 1000 grams, it may also affect full-term infants. Typically, in premature infants, NEC presents in the second or third week of life and is more common in formula-fed infants, while NEC in full-term infants presents in the first 3 days of life. Prematurity and breastfeeding are 2 risk factors for the development of NEC. Mortality from NEC ranges from 15%-30% and is inversely proportional to gestational age and birth weight.

Symptoms include vomiting, diarrhea, high residual feed volume, rectal bleeding, and abdominal distension characterized by increased abdominal girth or abdominal wall erythema. Systemic signs such as apnea, lethargy, respiratory failure, thermostability, and hypotension are also possible. Abdominal x-ray may show dilated loops of bowel consistent with ileus, pneumatosis intestinalis, or pneumoperitoneum in the case of perforation. Diagnosing NEC as soon as possible to allow for prompt medical management is key. The Bell staging criteria can be used to classify the severity of illness, but management is based on clinical presentation.

If NEC is suspected, enteral feeds should be suspended and evaluation for NEC should commence.