What is the management of Necrotizing Enterocolitis (NEC) in infants?

From the Guidelines

Management of necrotizing enterocolitis (NEC) in infants requires prompt intervention with a combination of medical and sometimes surgical approaches, with the most recent and highest quality evidence suggesting the use of probiotics, specifically combinations of Lactobacillus spp and Bifidobacterium spp, to prevent NEC in preterm infants less than 37 weeks gestational age and low birth weight 1.

Key Components of Management

• Initial management includes bowel rest by stopping all enteral feeds, gastric decompression with a nasogastric tube, and broad-spectrum antibiotics typically for 7-14 days.
• The antibiotic regimen usually includes ampicillin (50 mg/kg/dose) plus gentamicin (4-5 mg/kg/day) and metronidazole (15 mg/kg loading dose, then 7.5 mg/kg/dose every 12 hours) to cover gram-positive, gram-negative, and anaerobic bacteria, as recommended by the Surgical Infection Society and the Infectious Diseases Society of America 1.
• Supportive care is crucial, including fluid resuscitation with isotonic crystalloids (10-20 mL/kg boluses as needed), correction of electrolyte abnormalities, respiratory support, and blood product transfusions to maintain hemoglobin above 10 g/dL.
• Parenteral nutrition should be initiated to provide nutritional support during bowel rest.
• Surgical consultation is essential, with surgery indicated for intestinal perforation, peritonitis, abdominal wall erythema, or clinical deterioration despite medical management, with urgent or emergent operative intervention, consisting of either laparotomy or percutaneous drainage, and intraoperative Gram stains and cultures should be obtained 1.

Use of Probiotics

• The use of probiotics, specifically combinations of Lactobacillus spp and Bifidobacterium spp, has been shown to reduce all-cause mortality and severe NEC in preterm infants less than 37 weeks gestational age and low birth weight, with moderate- or high-quality evidence 1.
• The most effective probiotic strains for preventing NEC include L rhamnosus ATCC 53103 and B longum subsp infantis, L casei and B breve, and L acidophilus and B longum subsp infantis, among others 1.

Monitoring and Follow-up

• Serial abdominal radiographs every 6-12 hours are necessary to monitor disease progression.
• Once the infant improves clinically (typically after 7-10 days), enteral feeds can be slowly reintroduced, starting with small volumes of breast milk when possible.
• Close monitoring of the infant's condition and adjustment of the management plan as needed are crucial to ensure the best possible outcome.

From the Research

Management of Necrotizing Enterocolitis (NEC) in Infants

• NEC is an inflammatory disease of the gastrointestinal tract characterized by ischemic necrosis of the intestinal mucosa, mostly affecting premature neonates 2.
• The management of NEC includes medical care and surgical approaches, with supportive care and empirical antibiotic therapy recommended to avoid any disease progression 2.

Antibiotic Therapy for NEC

• No antimicrobial regimen has been shown to be superior to ampicillin and gentamicin in decreasing mortality and preventing clinical deterioration in NEC 2.
• The use of additional antibiotics providing anaerobic coverage, typically metronidazole, or use of other broad-spectrum regimens as first-line empiric therapy is not supported by the very limited current evidence 2, 3.
• A study comparing two antibiotic regimens for neonatal NEC found that cefotaxime and vancomycin may be more effective than ampicillin and gentamicin in smaller infants 4.
• Broad-spectrum antibiotic plus metronidazole may not prevent the deterioration of NEC in full-term and near-term infants 3.

Current Practices and Future Directions

• Guidelines regarding the administration of antibiotics for the treatment of NEC are lacking, and practices vary amongst clinicians 5.
• The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC, while others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC 5.
• A systematic review found no sufficient evidence to recommend a specific antibiotic regimen, route of administration, or duration for infants treated for NEC with Bell's stage II and III 6.