Feedings stopped

Nasogastric suction

Fluid resuscitation

Broad-spectrum antibiotics

TPN

1. Sometimes surgery
The mortality rate is 20 to 30%. Aggressive support and judicious timing of surgical intervention maximize the chance of survival.

2. Support
Nonsurgical support is sufficient in over 75% of cases. Feedings must be stopped immediately if NEC is suspected, and the intestine should be decompressed with a double-lumen NGT attached to intermittent suction. Appropriate colloid and crystalloid parenteral fluids must be given to support circulation, because extensive intestinal inflammation and peritonitis may lead to considerable 3rd-space fluid loss. TPN is needed for 14 to 21 days while the intestine heals.

Systemic antibiotics should be started at once with a beta-lactam antibiotic (eg, ampicillin, ticarcillin) and an aminoglycoside. Additional anaerobic coverage (eg, clindamycin, metronidazole) may also be considered and should continue for 10 days (for dosage, see Table: Recommended Dosages of Selected Parenteral Antibiotics for Neonates). Because some outbreaks may be infectious, patient isolation should be considered, particularly if several cases occur within a short time.

The infant requires close monitoring; frequent complete reevaluation (eg, at least every 12 h); and serial abdominal x-rays, CBCs, platelet counts, and blood gases. Intestinal strictures are the most common long-term complication of NEC, occurring in 10 to 36% of infants who survive the initial event. Strictures typically manifest within 2 to 3 mo of an NEC episode. Strictures are most commonly noted in the colon, especially on the left side. Resection of the stricture is then required.

3. Surgery
Surgical intervention is needed in < 25% of infants. Absolute indications are intestinal perforation (pneumoperitoneum), signs of peritonitis (absent intestinal sounds and diffuse guarding and tenderness or erythema and edema of the abdominal wall), or aspiration of purulent material from the peritoneal cavity by paracentesis. Surgery should be considered for an infant with NEC whose clinical and laboratory condition worsens despite nonsurgical support.

During surgery, gangrenous bowel is resected, and ostomies are created. (Primary reanastomosis may be done if the remaining intestine shows no signs of ischemia.) With resolution of sepsis and peritonitis, intestinal continuity can be reestablished several weeks or months later.