1. Necrotizing Enterocolitis
Management

2. Nonsurgical Medical Management For NEC
NPO
Platelet transfusions (thrombocytopenia)
Gastric decompression
FFP for DIC
Antibiotics
Careful management of I/O’s
Serial x-rays (q4-6hrs)
Abdominal girth measurements
Respiratory support as needed
Monitor blood glucose
Circulatory support as needed to treat hypotension
Frequent CBC and electrolyte panels

4. Fluid Management
Fluid restrict with higher glucose concentration depending on need for volume resuscitation
Monitor gi losses from repoglye at low intermittent suction
Replace fluid losses mL for mL as needed for excessive losses
Replace electrolytes as needed

5. Management
Antibiotics: Vancomycin, Gentamicin and Clindamycin for adequate coverage
Continue antibiotic coverage for 10 to 14 days, longer if cultures positive or condition warrants
Volume support to keep blood pressure in normal range
Inotropic drugs as indicated to improve blood pressure and cardiac output

6. Surgical Management
Surgery is necessary if medical management is not possible or fails.

7. Surgical Management Indications for surgery
Absolute indications: pneumoperitoneum, intestinal gangrene
Relative indications: progressive acidosis and/or thrombocytopenia, leukopenia/leukocytosis, progressive pneumatosis, persistent fixed dilated loops of bowel, abdominal wall erythema and/or edema, and portal venous gas

8. Surgical Procedure Most common
Resect obvious necrotic bowel and create stomas
If a large amount of bowel is involved, a second exploration is performed 24-48hrs
later to reevaluate bowel viability
More recently
Peritoneal drains for infants <1kg
and/or extremely unstable infants

9. Peritoneal Drains
~ 80% of infants <1kg will NOT survive surgical resection for NEC
Peritoneal drains decompress the peritoneal cavity and remove stool/necrotic debris
Local anesthetic and sedation
Incisions RLQ or RLQ and LLQ
Penrose or Jackson Pratt drains
Cavity is irrigated (NS) to remove
other contaminants
Drains remain for 1-2 weeks to allow for drainage
Most common complication: stricture formation

10. Postoperative Care Pain management minimum of 24 to 48 hours
PCVL or CVL for long term TPN
Antibiotics 14d+ (Vancomycin,
Gentamicin, +/-Clindamycin)
NPO and Gastric decompression
Maintenance of glucose homeostasis, fluid and electrolyte balance
Monitor lab work
Observation of stomas for color and drainage

11. Postoperative Care
Very slow resumption of feeds 10-14d post-op (varies depending on clinical status and previous feeding history)
Consult: Pediatric GI for long term follow up

12. Reanastomosis Usually 1-2 months post-op Factors evaluated Weight gain
Excessive ostomy output
Resect during reanastomosis
70-80% survival rate after
surgical NEC

13. Complications/Sequelae of NEC
Approximately 75% of infants who develop NEC survive.
Half of surviving infants incur long term complications
Most common  intestinal stricture

14. Intestinal Stricture
Former ischemic area  heals  fibrosis  scars narrowed lumen
Most common in non operative NEC
Stricture in L colon is
most common
Presents as FTT and/or blood stools

15. Other Sequelae of NEC Intestinal malabsorption
Loss of bowel length  decreased absorptive surface
Vitamin B12 deficiency
Bile salt deficiency
Intestinal hypermotility
Bacterial overgrowth

16. Other Sequelae of NEC
Cholestatic liver disease and rickets (epiphyseal dysplasia and skeletal deformities)
TPN dependence
Recurrent NEC
4-6% of patients
Neurodevelopmental disorders
May be function of prematurity
Dumping related to stoma placement and/or short bowel syndrome

17. Short Bowel Syndrome
Syndrome of malabsorption and malnutrition as a result of bowel shortening
<30% of small bowel or <75cm of small bowel
Severity associated with excess bowel loss and loss of illeocecal valve

18. A Little Bit of Trivia Estimated length of bowel in neonates
19-27 week GA: cm
32 week GA: 180cm + 42cm
35 week GA: 220cm + 50cm
For survival via enteral nutrition, neonates require
15cm of jejunum and ileum with ileocecal valve OR
40cm of jejunum and ileum without ileocecal valve

19. Prevention of NEC Prevent premature birth
If premature birth cannot be avoided, several preventative strategies remain
Antenatal steroids  induces gut maturation
High index of suspicion
Early intervention

20. Other Sequelae of NEC Early trophic feeding Optimize enteral feedings
Mom’s milk is best – feed colostrum/breast milk

21. Advance to Cases