Necrotising Enterocolitis (NEC)
History
Typically affects preterm infants in their second or third week of life in the neonatal unit who are formula fed. In term infants, the reported median age of onset is 1-3 days, but onset may occur as late as 1 month.
Initial symptoms may be subtle and can include 1 or more of the following:
Vomiting
Diarrhoea
Abdominal distention, abdominal tenderness
Ileus/decreased bowel sounds
Abdominal wall erythema (advanced stages)
PR bleeding
Examination
Can vary from mild disease to peritonitis, shock and death. The first signs are abdominal distention with gastric retention, emesis, and discomfort. Infants may also present shocked with circulatory collapse and episodes apnoea, or bleeding eg PR from consumptive coagulopathy.
Investigations
FBC – Hb – blood loss, WBC – sepsis, Plt – thrombocytopenia
EUC – hyponatraemia
Lactate and bicarb – poor tissue perfusion, sepsis, infarction of bowel
Glucose
DIC and coags – consumptive coagulopathy
G&H +/- X-match depending on severity of bleeding
Blood and stool cultures
AXR – abnormal gas pattern, dilated loops, thickened bowel wall, free air, portal gas
USS (bedside) – free fluid. Formal USS can identify areas loculation +/- abscess and walled off perforation.
Treatment
Cease feeding
NG decompression
IV/IO fluid resuscitation
Electrolyte monitoring and replacement
ABx following cultures e.g.
Ampicillin 50mg/kg/dose iv/im 8 hourly
Gentamicin 5mg/kg iv/im 24 hourly
Metronidazole initial loading dose 15mg/kg
Close monitoring
Surgical and paediatric specialist review
Likely early retrieval to specialist paediatric centre
Further References and Resources
Murphy, S. (2008) 'Management of bloody diarrhoea in children in primary care', BMJ, vol. 336, pp. 1010-1015
Springer, S. et al. 'Necrotizing Enterocolitis', Medscape, 10 November 2014