What is the treatment for necrotizing enterocolitis (NEC)?

Treatment of Necrotizing Enterocolitis

Immediate initiation of broad-spectrum intravenous antibiotics combined with bowel rest, nasogastric decompression, and aggressive fluid resuscitation forms the cornerstone of NEC management, with urgent surgical intervention required for intestinal perforation or clinical deterioration despite maximal medical therapy. 1, 2

Initial Resuscitation and Stabilization

Make the infant NPO immediately and place a nasogastric tube for bowel decompression to reduce abdominal distension and prevent further complications. 1, 2

• Administer fluid resuscitation at rates exceeding ongoing fluid losses to address hemodynamic instability, as these patients can lose copious amounts of fluid from inflamed bowel. 1
• Provide intensive hemodynamic monitoring with management of sepsis/septic shock if present. 2
• Monitor for thrombocytopenia, neutropenia, and metabolic acidosis through serial laboratory assessments. 2
• Perform serial abdominal examinations to detect early signs of perforation or clinical deterioration. 1

Antibiotic Therapy

Start broad-spectrum intravenous antibiotics immediately upon diagnosis covering gram-negative, gram-positive, and anaerobic organisms. 1

First-Line Regimens:

• Triple therapy: Ampicillin + gentamicin + metronidazole 3, 1, 2
• Alternative triple therapy: Ampicillin + cefotaxime + metronidazole 2
• Monotherapy option: Meropenem as single agent 2

Modified Regimens for Specific Scenarios:

• For suspected MRSA or ampicillin-resistant enterococcal infection: Substitute vancomycin for ampicillin 1, 2
• For suspected fungal infection in extremely low birth weight infants (<1000g): Add fluconazole or amphotericin B to the regimen 1, 2

The traditional three-drug regimen of gentamicin, ampicillin, and clindamycin (or metronidazole) has been successfully used for decades in pediatric complicated intra-abdominal infections. 3

Surgical Indications and Timing

Urgent surgical intervention is mandatory when any of the following are present:

• Pneumoperitoneum or free air on imaging indicating intestinal perforation 2
• Clinical deterioration despite maximal medical therapy including worsening hemodynamic instability, progressive abdominal distension, or increasing metabolic acidosis 2

Surgical Options:

• Laparotomy with resection of necrotic bowel and creation of ostomies (preferred approach) 2
• Peritoneal drainage as temporizing measure or definitive treatment specifically in very low birth weight neonates with perforation 3, 2
• Obtain intraoperative Gram stains and cultures to guide antimicrobial therapy. 2

Nutritional Management

• Maintain NPO status during the acute phase to allow bowel rest. 1
• Once the acute phase resolves, attempt enteral nutrition through nasogastric or nasoenteric tube when the gut can tolerate it. 1
• Supplement with parenteral nutrition if the gut cannot absorb all nutritional needs. 1

Monitoring Response to Treatment

Clinical improvement is indicated by:

• Decreased abdominal distension 1
• Resolution of bloody stools 1
• Improved hemodynamic parameters 1
• Normalization of laboratory values including resolution of thrombocytopenia and neutropenia 1

Critical Pitfalls to Avoid

Never use anticholinergic, antidiarrheal, or opioid agents as they aggravate ileus and mask clinical deterioration. 1, 2

Do not delay surgical consultation when signs of perforation or clinical deterioration appear, as failure to remove necrotic bowel in these severely compromised patients is often fatal. 2

Prognosis

• Survival rate approaches 95% when NEC is localized to a bowel segment. 3, 2
• When NEC involves the entire bowel (occurs ~25% of the time), mortality increases dramatically to 40-90%. 3, 2
• Nonoperative management succeeds in approximately 70% of cases. 3, 2

Prevention Strategies

While not treatment per se, these strategies reduce NEC incidence in at-risk populations:

• Probiotics (combinations of Lactobacillus spp. and Bifidobacterium spp.) reduce the risk of severe NEC and mortality in preterm infants. 1, 2
• Lactoferrin alone or combined with Lactobacillus may reduce late-onset sepsis including Candida infections. 1, 2
• Antifungal prophylaxis should be considered for extremely low birth weight infants (<1000g). 2

Human breast milk feeding and standardized feeding protocols represent evidence-based preventive measures. 4