Management of necrotizing enterocolitis in newborns
- Richard J Schanler, MD
Richard J Schanler, MD
- Hofstra Northwell School of Medicine
Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant. It is a disorder characterized by ischemic necrosis of the intestinal mucosa, which is associated with inflammation, invasion of enteric gas forming organisms, and dissection of gas into the muscularis and portal venous system . Although early recognition and aggressive treatment of this disorder have improved clinical outcomes, NEC accounts for substantial long-term morbidity in survivors of neonatal intensive care, particularly in premature very low birth weight infants (birth weight below 1500 g).
The management of NEC depends upon the severity of illness as classified by the Bell staging criteria (table 1). Medical management is appropriate in most cases. However, infants with advanced NEC and bowel perforation (stage IIIB) require surgical intervention. Care for the infant with (or suspected) NEC is provided by a multi-disciplinary team, which includes surgical consultation that assists the neonatology team in the evaluation and management of the infant, and decides if and when surgery is needed.
The treatment and outcome of NEC will be reviewed here. The pathology, pathogenesis, clinical features, diagnosis, and prevention of this disorder are discussed separately. (See "Pathology and pathogenesis of necrotizing enterocolitis in newborns" and "Clinical features and diagnosis of necrotizing enterocolitis in newborns" and "Prevention of necrotizing enterocolitis in newborns".)
Overview — Medical management should be initiated promptly when necrotizing enterocolitis (NEC) is suspected. It consists of the following:
- Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am 1996; 43:409.
- Kliegman RM, Fanaroff AA. Necrotizing enterocolitis. N Engl J Med 1984; 310:1093.
- Faix RG, Polley TZ, Grasela TH. A randomized, controlled trial of parenteral clindamycin in neonatal necrotizing enterocolitis. J Pediatr 1988; 112:271.
- Bell MJ, Ternberg JL, Bower RJ. The microbial flora and antimicrobial therapy of neonatal peritonitis. J Pediatr Surg 1980; 15:569.
- Brook I. Microbiology and management of neonatal necrotizing enterocolitis. Am J Perinatol 2008; 25:111.
- Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006; 368:1271.
- Autmizguine J, Hornik CP, Benjamin DK Jr, et al. Anaerobic antimicrobial therapy after necrotizing enterocolitis in VLBW infants. Pediatrics 2015; 135:e117.
- Shah D, Sinn JK. Antibiotic regimens for the empirical treatment of newborn infants with necrotising enterocolitis. Cochrane Database Syst Rev 2012; :CD007448.
- Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.
- Egan EA, Mantilla G, Nelson RM, Eitzman DV. A prospective controlled trial of oral kanamycin in the prevention of neonatal necrotizing enterocolitis. J Pediatr 1976; 89:467.
- Hansen TN, Ritter DA, Speer ME, et al. A randomized, controlled study of oral gentamicin in the treatment of neonatal necrotizing enterocolitis. J Pediatr 1980; 97:836.
- Epelman M, Daneman A, Navarro OM, et al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics 2007; 27:285.
- Tepas JJ 3rd, Sharma R, Leaphart CL, et al. Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement. J Pediatr Surg 2010; 45:310.
- Flake AW. Necrotizing enterocolitis in preterm infants--is laparotomy necessary? N Engl J Med 2006; 354:2275.
- Rao SC, Basani L, Simmer K, et al. Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low birth weight infants. Cochrane Database Syst Rev 2011; :CD006182.
- Moore TC. Successful use of the "patch, drain, and wait" laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered "good angiogenesis" involved? Pediatr Surg Int 2000; 16:356.
- Moss RL, Dimmitt RA, Barnhart DC, et al. Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. N Engl J Med 2006; 354:2225.
- Rees CM, Eaton S, Kiely EM, et al. Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial. Ann Surg 2008; 248:44.
- Rees CM, Eaton S, Khoo AK, et al. Peritoneal drainage does not stabilize extremely low birth weight infants with perforated bowel: data from the NET Trial. J Pediatr Surg 2010; 45:324.
- Blakely ML, Tyson JE, Lally KP, et al. Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 months adjusted age. Pediatrics 2006; 117:e680.
- Schwartz MZ, Richardson CJ, Hayden CK, et al. Intestinal stenosis following successful medical management of necrotizing enterocolitis. J Pediatr Surg 1980; 15:890.
- Horwitz JR, Lally KP, Cheu HW, et al. Complications after surgical intervention for necrotizing enterocolitis: a multicenter review. J Pediatr Surg 1995; 30:994.
- Lemelle JL, Schmitt M, de Miscault G, et al. Neonatal necrotizing enterocolitis: a retrospective and multicentric review of 331 cases. Acta Paediatr Suppl 1994; 396:70.
- Heida FH, Loos MH, Stolwijk L, et al. Risk factors associated with postnecrotizing enterocolitis strictures in infants. J Pediatr Surg 2016; 51:1126.
- Schimpl G, Höllwarth ME, Fotter R, Becker H. Late intestinal strictures following successful treatment of necrotizing enterocolitis. Acta Paediatr Suppl 1994; 396:80.
- Buonomo C. The radiology of necrotizing enterocolitis. Radiol Clin North Am 1999; 37:1187.
- Radhakrishnan J, Blechman G, Shrader C, et al. Colonic strictures following successful medical management of necrotizing enterocolitis: a prospective study evaluating early gastrointestinal contrast studies. J Pediatr Surg 1991; 26:1043.
- Salvia G, Guarino A, Terrin G, et al. Neonatal onset intestinal failure: an Italian Multicenter Study. J Pediatr 2008; 153:674.
- Cole CR, Hansen NI, Higgins RD, et al. Bloodstream infections in very low birth weight infants with intestinal failure. J Pediatr 2012; 160:54.
- Duro D, Kalish LA, Johnston P, et al. Risk factors for intestinal failure in infants with necrotizing enterocolitis: a Glaser Pediatric Research Network study. J Pediatr 2010; 157:203.
- Snyder CL, Gittes GK, Murphy JP, et al. Survival after necrotizing enterocolitis in infants weighing less than 1,000 g: 25 years' experience at a single institution. J Pediatr Surg 1997; 32:434.
- Abdullah F, Zhang Y, Camp M, et al. Necrotizing enterocolitis in 20,822 infants: analysis of medical and surgical treatments. Clin Pediatr (Phila) 2010; 49:166.
- Hull MA, Fisher JG, Gutierrez IM, et al. Mortality and management of surgical necrotizing enterocolitis in very low birth weight neonates: a prospective cohort study. J Am Coll Surg 2014; 218:1148.
- Fitzgibbons SC, Ching Y, Yu D, et al. Mortality of necrotizing enterocolitis expressed by birth weight categories. J Pediatr Surg 2009; 44:1072.
- Lambert DK, Christensen RD, Baer VL, et al. Fulminant necrotizing enterocolitis in a multihospital healthcare system. J Perinatol 2012; 32:194.
- Clark RH, Gordon P, Walker WM, et al. Characteristics of patients who die of necrotizing enterocolitis. J Perinatol 2012; 32:199.
- Pike K, Brocklehurst P, Jones D, et al. Outcomes at 7 years for babies who developed neonatal necrotising enterocolitis: the ORACLE Children Study. Arch Dis Child Fetal Neonatal Ed 2012; 97:F318.
- Hintz SR, Kendrick DE, Stoll BJ, et al. Neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis. Pediatrics 2005; 115:696.
- Rees CM, Pierro A, Eaton S. Neurodevelopmental outcomes of neonates with medically and surgically treated necrotizing enterocolitis. Arch Dis Child Fetal Neonatal Ed 2007; 92:F193.
- Martin CR, Dammann O, Allred EN, et al. Neurodevelopment of extremely preterm infants who had necrotizing enterocolitis with or without late bacteremia. J Pediatr 2010; 157:751.
- Schulzke SM, Deshpande GC, Patole SK. Neurodevelopmental outcomes of very low-birth-weight infants with necrotizing enterocolitis: a systematic review of observational studies. Arch Pediatr Adolesc Med 2007; 161:583.
- MEDICAL MANAGEMENT
- Supportive care
- Antibiotic therapy
- Laboratory monitoring
- Radiographic monitoring
- SURGICAL MANAGEMENT
- - Primary peritoneal drainage
- - Laparotomy
- - Comparison of procedures
- - Our approach
- Acute complications
- Late complications
- - Stricture formation
- - Short bowel syndrome
- - Rare complications
- Long-term outcome
- - Growth and neurodevelopment
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS