Necrotizing Enterocolitis

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What is necrotizing enterocolitis?

Necrotizing enterocolitis is infection and inflammation of the intestines. The disease is most common among premature newborns. Many newborns who develop necrotizing enterocolitis survive and go on to live healthy lives. But if the infection becomes severe, it can cause serious damage to or holes in the intestinal tissue, which can be life-threatening.

Necrotizing enterocolitis most commonly develops 10 to 16 days after birth, usually while a premature newborn is still in the hospital. In some cases, necrotizing enterocolitis develops up to 3 months after birth.

See a picture of necrotizing enterocolitis.

What causes necrotizing enterocolitis?

The cause of necrotizing enterocolitis is not clear. It is believed to occur when the immune and digestive systems do not develop properly. This can happen when a baby is born prematurely or when there are complications during pregnancy or delivery.

Experts do not know if feeding a newborn formula can lead to necrotizing enterocolitis, but they do know that the disease is much less common in babies who are fed breast milk.

What are the symptoms?

Often, a newborn baby is feeding well, healthy, and growing before he or she develops any symptoms of necrotizing enterocolitis. A baby's symptoms depend on how severe the condition is. If your baby has necrotizing enterocolitis, he or she may:

• Have a swollen, tender, red, or shiny belly.
• Not want to eat, or may be throwing up (vomiting).
• Be constipated.
• Have dark, black, or bloody stools.
• Have low or unstable body temperature.
• Not be very active, or may have little energy.

How is necrotizing enterocolitis diagnosed?

Necrotizing enterocolitis is diagnosed from a newborn's symptoms, medical history, and test results. Tests may include an abdominal X-ray to provide a picture of your newborn's intestines; a test to check for blood in the stool (fecal occult blood test); and other tests to check for bacteria in the stool, blood, urine, or spinal fluid.

How is it treated?

If your newborn has necrotizing enterocolitis, he or she will need to be treated in a hospital, often in a neonatal intensive care unit (NICU). In newborns who have mild to moderate necrotizing enterocolitis, treatment consists of intravenous (IV) feeding, antibiotics, and removing extra fluids and gas from the intestine. This treatment usually lasts between 3 and 10 days.

If your newborn does not improve with treatment, or if he or she gets a hole in the intestines, surgery to remove damaged parts of the intestines may be necessary. Up to half of newborns with necrotizing enterocolitis need surgery.¹ Many newborns who have surgery for necrotizing enterocolitis survive and go on to live healthy lives.

Frequently Asked Questions

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	Caring for your ostomy

Often, a newborn baby is feeding well, healthy, and growing before there are any signs of necrotizing enterocolitis. Typically, a doctor or nurse will notice signs and symptoms of the disease 4 to 10 days after your newborn begins milk feeding. (Sometimes a premature newborn is first fed through a tube.) But symptoms may appear as soon as 4 hours or as late as 3 months after birth.

If your newborn has mild or moderate necrotizing enterocolitis, he or she may:

• Have a swollen, tender, red or shiny belly, with a firm loop of bowel in the intestines that your doctor can feel.
• Not want to eat, or may be throwing up (often greenish or greenish yellow vomit), which can lead to dehydration.
• Have a change in bowel movements. This includes:
  • Dark, black, or bloody stools.
  • Delayed passage of meconium in the first 24 to 48 hours after birth.
  • Fewer bowel movements than expected, or diarrhea.
• Be short of breath or stop breathing for longer than 10 seconds.
• Have a low or unstable body temperature.
• Not be very active, or may have little energy.
• Have few or no bowel sounds—the normal gurgling, rumbling, or growling noises in the stomach. If your baby does not have these noises, it can mean that his or her digestive system is not working well.

Less than half of the time, a newborn will have more serious symptoms that indicate severe necrotizing enterocolitis and may require surgery. These symptoms include:

• Infection in the belly area (peritonitis). Your baby may have a swollen, hard belly; severe belly pain and tenderness; nausea and vomiting; a fast heartbeat; chills and fever; and rapid breathing.
• Bleeding in the intestines.
• Tissue death (necrosis) in part of the intestines.
• Infection in the blood (sepsis).
• Difficulty clotting blood (disseminated intravascular coagulation, or DIC). DIC often damages every organ in the body.
• Heart or lung failure.
• Shock.

Necrotizing enterocolitis may be mistaken for other conditions with similar symptoms.

A diagnosis of necrotizing enterocolitis is based on your baby's medical history, symptoms, and:

• An abdominal X-ray, to provide a picture of the intestines. If your child has necrotizing enterocolitis, the X-ray may show a sausage-shaped intestine, often with air in the walls of the intestines.
• A fecal occult blood test, to check for blood in your baby's stool.
• A stool culture, to examine your baby's stool and to look for a specific kind of bacteria.
• A spinal fluid test, to determine the amount of blood cells, protein, glucose, and bacteria in the fluid around your baby's spinal cord.
• A blood culture, to identify any bacteria in your baby's blood.
• A urine test, to look for any signs of infection or bacteria in your baby's urine.

Monitoring necrotizing enterocolitis

After diagnosis, your baby may need to have more tests to monitor the disease, including:

• Abdominal X-rays. An abdominal X-ray can show whether the infection is improving or getting worse. X-rays are repeated every 6 to 8 hours.
• A paracentesis. If X-ray results are not clear, your doctor may take a sample of fluid from your baby's belly. If some of the contents of the intestines are found in this fluid, it means there is a hole in your baby's intestines.
• An abdominal ultrasound. This imaging test may be used to see if your baby's intestine is infected and inflamed.
• An arterial blood gas test. This test can tell whether your baby has enough oxygen in his or her blood.
• A complete blood count (CBC). This test looks at the different parts of your baby's blood to determine how well he or she can fight infection.

MRI tests are currently being studied for use in infants with severe necrotizing enterocolitis as a way to see how much intestinal tissue is damaged.² This is only at the research stage right now.

No matter what kind of treatment your newborn needs for necrotizing enterocolitis, it can be stressful to watch a fragile newborn undergo medical treatment. You may find that you feel overwhelmed by having a new baby with health problems. You may feel frustrated if you cannot hold your baby as often as you want or if you cannot breast-feed your baby, but instead have to pump your milk, which is then given to your baby through a tube. It can be helpful to talk about your feelings and concerns with a social worker or counselor. It is also a good idea to get to know the team of health professionals involved in your baby's care and to ask them questions about anything you do not understand.

Newborns with necrotizing enterocolitis may be treated by a variety of health professionals, including:

• Neonatologists.
• Gastroenterologists.
• Dietitians.
• Pediatric surgeons.

How much treatment your baby needs depends on how severely his or her intestines are damaged.

All newborns with necrotizing enterocolitis require:

• Temporary use of a nasogastric tube, which is inserted through the nose into the stomach to remove extra fluids and gas from the intestines.
• Daily measurement of your newborn's belly. If your baby's belly gets smaller, or he or she is able to pass stools, then the intestines are working normally again.

If your baby has mild necrotizing enterocolitis, treatment generally lasts 72 hours. If your baby has moderate necrotizing enterocolitis, treatment may continue for 7 to 10 days.

If your baby has severe necrotizing enterocolitis, treatment can last up to 21 days and may include:

• Oxygen therapy and possible treatment with a ventilator to make sure your baby is getting enough oxygen.
• A series of abdominal X-rays to see if the infection in the intestines is getting better or worse.
• Blood transfusions when there is a lot of bleeding or infection.
• Drugs such as dopamine that cause the heart to pump more blood, to increase blood pressure.

If your baby's intestines are healing, he or she may continue to get IV fluids while oral feedings are started. Most babies who have mild or moderate necrotizing enterocolitis will not have any ongoing problems with digestion, nutrition, and growth.

Surgery

If your baby has severe necrotizing enterocolitis and has a hole in the intestines, seriously damaged intestinal tissue, or bowel obstruction, he or she may need surgery. If surgery is required, it has two steps:

• In the first surgery, the upper part of the intestine is brought to the surface of the belly and a colostomy or ileostomy is created. The lower part of the intestine then does not have to digest food, which allows it to heal. In addition, severely damaged sections of the intestine are removed.
• The second surgery is performed weeks or months later, after the damaged intestine has healed. This surgery involves:
  • Closing the colostomy or ileostomy.
  • Surgically reconnecting a healthy upper section of the intestine to a healthy lower section (end-to-end anastomosis). This surgery allows body waste to pass normally through the intestines and leave the body through the newborn's rectum.

For several days after each surgery, your baby will be fed intravenously.

If your baby has only a small area of damaged tissue, some surgeons will do one surgery to remove the affected tissue and reconnect the intestines.

Complications

If your baby has surgery, he or she may develop a blockage of the intestine (stricture) up to 8 weeks after surgery. The symptoms of a blockage are the same as the symptoms of necrotizing enterocolitis. An X-ray can determine where the blockage is and what kind of treatment is needed.

Some newborns who have necrotizing enterocolitis later develop short bowel syndrome (short gut syndrome). Children with short bowel syndrome may not grow as tall, weigh as much, or develop as fast as other children their age because they cannot absorb enough calories from the food they eat. Infants with severe short bowel syndrome may need IV feeding for weeks or months. With training and support for caregivers, IV feeding may be done at home rather than at a hospital.

Many newborns who have necrotizing enterocolitis go on to live healthy lives, but about 1 out of 5 of these newborns do not survive.² Ongoing problems with digestion, growth, and development are most common both in infants who weighed less than 2.2 lb (1 kg) when they were born and in infants who had surgery to treat severe necrotizing enterocolitis.

After being treated for necrotizing enterocolitis, your newborn can leave the hospital when he or she has been feeding well enough to stay at the same weight or gain weight. Before you take your baby home, be sure you understand:

• How much and what to feed your baby so that his or her intestines heal and grow normally. Most newborns can be fed regular formula or breast milk. But if your newborn had surgery, he or she may need to eat a special formula.
• How to care for your newborn's colostomy or ileostomy. For more information, see Caring for your ostomy.
• The symptoms of an intestinal blockage, such as throwing up, a swollen belly, or any change in bowel movements. Contact your doctor immediately if your newborn has any of these symptoms.
• How to care for your newborn's incision.
• How often you need follow-up visits with your doctor.

If you think that you will need help caring for your newborn, talk to your doctor about contacting a pediatric home health agency. A home health agency can provide medical care for your baby in your home.

Online Resource

Organization

• Breast-Feeding
• Premature Infant

Citations

1. Berseth CL, Poenaru D (2005). Necrotizing enterocolitis and short bowel syndrome. In HW Taeusch et al., eds., Avery's Diseases of the Newborn, 8th ed., pp. 1123–1133. Philadelphia: Elsevier Saunders.

2. Stoll BJ, Kliegman RM (2004). Digestive system disorders. In RE Behrman et al., eds., Nelson Textbook of Pediatrics, 17th ed., pp. 588-599. Philadelphia: Saunders.

Other Works Consulted

• Brown RE, Neu J (2006). Necrotizing enterocolitis. In FD Burg et al., eds., Current Pediatric Therapy, 18th ed., pp. 293–296. Philadelphia: Saunders Elsevier.

• Pietz J, et al. (2006). Prevention of necrotizing enterocolitis in preterm infants: A 20-year experience. Pediatrics, 119(1): e164–e170.