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Necrotising Enterocolitis (NEC) in the neonate

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Necrotising enterocolitis (NEC) is a disease seen predominantly in premature babies. Refer to teaching information/radiology mages for background information.

Diagnosis of NEC

Early Signs
• Poor feeding/spilling. 
• Gastric aspirates, which may be bile stained. 
• Apnoea and bradycardia. 
• Unstable temperature. 
• Abdominal distension - painful and tense. 
• Bowel loops can be seen visibly under the skin. 
• Loose seedy stools. 
• Haematest positive stool. 
• Superficial veins on the abdomen in smaller, low weight infant become more prominent. 
• Diminishing, leading to absent bowel sounds. 
• Abdominal radiograph showing distension with mild ileus or fixed dilated loops. 
• Elevated glucose levels. 
Late Signs Indicating Actual Or Impending Bowel Perforation
• Lethargy. 
• Increasing apnoea and bradycardia. 
• Pallor and shock. 
• Poor tissue perfusion. 
• Mottling of extremities. 
• Decreased urine output. 
• Hypotension. 
• Decreasing haematocrit levels. 
• Decreased platelet count. 
• Increased white blood count. 
• Grossly bloody stools. 
• Hypothermia. 
• Unstable glucose levels. 
• Increase in abdominal distension (the abdomen becomes hard, red and warm: can also be shiny and discoloured). 
• May become discoloured over the suspected area of perforation, or around the umbilicus. 
Later Signs
• Deterioration of vital signs. 
• Evidence of septic shock or marked gastro-intestinal haemorrhage. 
• Abdominal radiographs show pneumoperitoneum (free air in peritoneal cavity). 
• Disseminated intravascular coagulation (DIC).

Indications for Surgery

In general, surgery is indicated when the bowel has necrosed.

It is difficult to make the diagnosis of intestinal gangrene before the development of complications. The challenge is to avoid operating on the infant with NEC who does not have necrosis, yet not delay operating on the infant who does.

Absolute Indications for Surgery

  • Perforation with NEC as indicated by radiograph. 
  • (Note that the NET trial is currently evaluating immediate laparotomy versus peritoneal drainage) 

Relative Indications for Surgery are Signs of Progressive Disease

The following almost always indicate intestinal necrosis has developed:

  • Portal venous gas 
  • Abdominal mass 
  • Inflammation and oedema of the abdominal wall 
  • Increasing tenderness 
  • Persistence of a fixed dilated loop of intestine on serial abdominal x-rays, which usually indicates ischaemic bowel. 
  • DIC and acidosis not responding to conservative treatment. 
  • Clinical deterioration. 
  • Failure to improve with medical treatment, even if the DIC or acidosis is mild 

Conservative Care

  1. Ensure continuous monitoring is maintained and hourly recording of: 
    1. cardiorespiratory status 
    2. invasive blood pressure (or 2-4 hourly by Dinamap) 
    3. SpO2
    4. skin temperature/axilla temp monitoring
    5. Report immediately any changes in baseline levels to doctor/NS-ANP.
  2. Ventilation as per doctors/NS-ANPs instructions. 4 hourly ABG/CBG and/or prn as ordered by doctor/NS-ANP. 
  3. The baby is to remain nil by mouth for 10-14 days or longer (primarily to rest the intestines). Intravenous nutrition will be prescribed by doctor/NS-ANP 
  4. An orogastric tube (size 8) is inserted. 
    1. Place on free drainage. 
    2. Aspirate every 4-6 hours and replace fluid losses intravenously as prescribed (usually with 0.9% NaCl plus 10mmol KCl/500ml). 
    3. The colour, consistency and amount of gastric aspirates is recorded. 
  5. Measure and record fluid balance accurately:-
    1. Urine output. 
    2. 6-hourly total. 
    3. Urinalysis at each nappy change. 
  6. Measure and record abdominal girth 6 hourly/major handling (immediately above umbilicus). 
  7. Record bowel motions and test stools for blood as per orders.

Preoperative care

  1. Follow standard steps for preoperative care

Postoperative care

  1. Follow the standard steps for postoperative care
  2. The baby remains nil by mouth. 
  3. An orogastric tube (size 8) is inserted. 
    1. Place on free drainage. 
    2. Aspirate every 4-6 hours and replace fluid losses intravenously as prescribed (usually with 0.9% NaCl plus 10mmol KCl/500ml). 
    3. The colour, consistency and amount of gastric aspirates is recorded. 
  4. Measure and record fluid balance accurately:-
    1. Urine output. 
    2. 6-hourly total. 
    3. Urinalysis at each nappy change. 
  5. No rectal temperatures.

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Document Control

  • Date last published: 04 April 2005
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years