CLINICAL GUIDELINES ID TAG

Title:

Guideline for the management of Necrotising

Enterocolitis

Author:

Clare Boyce, Dr M. Hogan

Designation:

CYP

Speciality / Division:

Neonatal

Directorate:

Acute Paediatrics

Date Uploaded:

24th November 2014

Review Date (Every 2 years

1st November 2016

or sooner if required):

Clinical Guideline ID:

CG0050

Guideline for the management of Necrotising Enterocolitis

Necrotising Enterocolitis (NEC) continues to be a primary cause of morbidity and mortality in

preterm neonates. Whilst identifiable risk factors include preterm birth and enteral feeding,
(Christensen et al 2010), it is also important to note that approximately 10% of cases occur
in term neonates. However in these cases NEC usually occurs as a secondary injury to a
known insult i.e. perinatal asphyxia, congenital heart disease, polycythaemia or maternal
cocaine abuse.

Aetiology
Aetiology is multifactorial with interaction of gut hypoxia, poor mucosal integrity, bacterial
flora and the presence of metabolic substrate. NEC is a transmural disease characterised by

coagulative necrosis, ulceration, oedema and haemorrhage of the gut. It can affect any part
of the bowel but predominantly involves terminal ileum, caecum and ascending colon.

Risk factors
Prematurity
Intrauterine growth restriction
Absent or reversed end-diastolic flow on umbilical arterial Doppler antenatally
Perinatal asphyxia
Low systemic blood flow during neonatal period (including duct-dependent congenital
heart disease)
Patent ductus arteriosus
Exchange transfusion
Formula milk
No antenatal corticosteroids
Infections with: klebsiella, enterobacter, anaerobes

Clinical presentation
Classical:

abdominal distension

blood in the stools

bile stained aspirates/vomit.

Non specific signs:

lethargy

temperature instability

apnoeic episodes

shock

respiratory failure

collapse

Diagnosis: Bells staging criteria for NEC enables physicians to make an accurate diagnosis of
NEC, initiating prompt management/ treatment to ill neonates.

Modified Bells staging criteria for NEC

Stage I
Suspected NEC
Non-specific signs: lethargy,
Temperature instability,
poor glucose tolerance.
GI manifestations: poor
feeding, increased gastric
aspirates, bilious vomiting,
mild abdominal distension,
abdominal tenderness,
faecal occult
blood.
AXR: within normal limits.

Stage II
Confirmed NEC
Stage I plus
Abdominal tenderness and
or guarding
Marked abdominal
distension.
Peri-umbilical flare
Blood or mucous in the
stool

Stage III
Advanced NEC
Stage II plus
Clinical deterioration
Evidence of septic shock
Marked GI haemorrhage
Abdominal wall
discolouration

AXR: Intestinal distension,

bowel wall oedema,
featureless
bowel loops, persistent or
unchanging bowel loops,
pneumatosis intestinalis,
portal venous gas

AXR: Stage II plus

Pneumoperitoneum.

INVESTIGATIONS
Abdominal X-ray
Supine antero-posterior view
If perforation suspected but not clear on supine view, left lateral view

Not all infants will have radiological findings associated with NEC, consider
asking the radiologist for opinion on the xray for NEC

Blood tests
FBC: anaemia, neutropenia and thrombocytopenia often present; early return to normal
indicates good prognosis
Blood film: evidence of haemolysis and toxic changes (e.g. spherocytes, cell fragments,
polychromatic cells)
C-reactive protein, but a normal value will not be helpful in initial phase
Urea and electrolytes
Blood gas: evidence of metabolic acidosis (base excess more negative than 10)
Coagulation screen
Blood cultures

Management
IMMEDIATE TREATMENT
Always discuss management with Consultant
In all stages
Transfer baby to neonatal intensive care and nurse in incubator to avoid cross infection
If respiratory failure and worsening acidosis, intubate and ventilate
Nil-by-mouth
Gastric decompression
Free drainage with large nasogastric tube (size 8) or continuous suction with 10 cm water

 NEC often associated with significant third spacing of fluid into mesentery
Triple antibiotics: Amoxicillin, gentamicin and metronidazole as per pharmacy guidelines
IV fluids/TPN: total volume 150 mL/kg or less
Long line when stable
Pain relief, consider morphine/fentanyl infusion
Suspected NEC (Bells Stage I)

If any classical signs of NEC or non-specific signs inform ANNP/Registrar/ Consultant

Stop enteral feeds immediately, insert a nasogastric tube on free drainage (gastric
decompression). Registrar/ ANNP will prescribe IV fluids/ TPN for the neonate.

Septic screen: fbp/crp/u&e/ bp/ blood cultures/ blood gas and blood glucose.

Order Abdominal XRay (AP view only) However if concerns arise over perforation
order a lateral XRay

Commence triple antibiotics therapy: Amoxicillin, Gentamicin and Metronidazole as

per pharmacy guidelines

Prescribe and administer appropriate analgesia

Repeat bloods and AXRs if clinical concerns persist.

If signs and symptoms resolve, consider discontinuing antibiotics after 48-72 hours
and recommence feeds or at consultants discretion.

Confirmed / Advanced NEC (Bells Stage II and III)

As Stage I plus

Consider need for early respiratory support by electively intubating and ventilating
neonate as increasing abdominal distension can cause diaphragmatic splinting and
CPAP may worsen this.

Early referral to the surgical team in RBHSC

Give early volume expansion if signs/symptoms suggest shock

Commence Inotropes if hypotensive

Gain central venous/ arterial access if possible

Correct any electrolyte abnormalities. Monitor urine output and catheterise if

necessary.

Commence morphine infusion

Correct anaemia, aim for Hb > 120gm/l.

Correct thrombocytopenia, aim for Platelets >50,0000. Obtain blood sample for
coagulation screen. If actively bleeding or deranged clotting factors administer FFP.

Repeat blood tests 8-12 hourly and blood gases 4 hourly or as clinically indicated.

Repeat the AXR if clinical concerns or deterioration

If concerns arise about perforation, consider lateral X-ray or right side up view (free
air should be easier to identify). Inform the consultant urgently if the AXR reveals
perforation. The surgical team should then be informed.

If improving with medical management, continue antibiotics for 7-10 days and NBM
for 10 days. Start enteral feeds when abdomen is soft, non-distended, non-tender
with normal bowel sounds and minimal aspirates.

SUBSEQUENT MANAGEMENT
In recovery phase
In Stage 1, if no progression after 48 hours, consider restarting feeds slowly and stopping
antibiotics.
In Stage 2, if abdominal examination normal after 10 days, consider restarting feeds, some
may need longer period of total gut rest and stop antibiotics after 710 days
In Stage 3, discuss with surgeon and dietician before restarting feeds

Surgery
50% of neonates with confirmed or advanced disease will require surgical intervention.
Usually a laparotomy is performed, however some patients will be too sick for theatre and
these patients may undergo peritoneal drainage on the unit. Indications for surgery include
failure to respond to maximal medical therapy, perforation, stricture and abdominal mass
with obstruction.
The consultant responsible for the neonatal unit or the on call consultant leads on the
care of the infant with suspected or confirmed NEC including referral to the Surgical Team
in RBHCS.

REFERENCES
Bell, M.J. et al (1978) Neonatal necrotising enterocolitis: therapeutic decisions based upon
clinical staging. Annals of Surgery, 187, pp. 1-7.
Cardiff and Vale UHB (2014) Guideline for the management of Necrotising Enterocolitis.
Available from www.cardiffandvaleuhb.wales.nhs.uk (Accessed 28th October 2013).
Christensen, R.D,

Gordon P.V., and Besner G.B. (2010) Can we cut the incidence of

necrotising enterocolitis in half- today? Fetal and Pediatric Pathology, 29 (4), pp 185-198.
Cincinnati Children's Hospital Medical Center (2010) Evidence-based care guideline for
necrotizing enterocolitis (NEC) among very low birth weight infants. Available from:
http://www.guideline.gov/content.aspx?id=24815 (Accessed on 21st June 2013)
Lin, P.W and Stoll, B. J (2006) Necrotising Enterocolitis. The Lancet, 368 (9543), pp.12711283
North Trent Neonatal Network Clinical Guideline (2011) Management of Necrotising
Enterocolitis. Avaliable from: www.northtrentneonatal.nhs.uk (Accessed on 21st June 2014)