Necrotizing Enterocolitis

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What is necrotizing enterocolitis?

In necrotizing enterocolitis (NEC), bacteria infect and irritate the bowels. The infection can cause part of the bowels to die.

“Enterocolitis” (pronounced ent-air-oh-co-LITE-iss) means inflamed bowels.
“Necrotizing” (pronounced nek-roh-TIE-zing) means it causes tissue death.

NEC may affect part or all of the bowels. It can be mild or life threatening.

In milder cases, the bowels may heal and be fine after medical treatment to fight the infection.
In more serious cases, a baby may need surgery to remove damaged parts of their bowels.
In the worst cases, the bowels may fail or the infection may overwhelm the baby’s body.

Who is more likely to get NEC?
- NEC most often affects babies who were born early (premature).
- Babies born with other health problems, such as heart defects or gastroschisis, may get NEC.
- Sometimes we treat older children who show signs of NEC on an X-ray of their bowels.
Causes of NEC
The cause of NEC is not clear. These factors seem to play a role:
- A baby’s bowels may not be mature enough or healthy enough to move food along well when the baby is fed.
- A baby’s immune system may not be strong enough to protect the bowels from bacteria or may overreact to an infection.
- Blood flow to the bowels may be poor.

Pediatric General and Thoracic Surgery at Seattle Children's

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Symptoms of Necrotizing Enterocolitis

Babies with NEC may have these symptoms:

Swollen belly (abdomen)
Pain in the belly
Vomit that is green because it contains bile
Red- or blue-colored blotches on the skin of the belly
Diarrhea or bloody poop (stools)
Tiredness or no energy (lethargy)
Problems keeping a normal body temperature
Breathing problems
Slow heart rate

Diagnosing Necrotizing Enterocolitis

Most of the children we treat for NEC are premature babies who are in the hospital for other treatment. If your child has symptoms of NEC, your child’s doctor will:

Ask about your child’s illness
Do a complete physical exam
Test your child’s blood
Possibly check your child’s poop (stool) for blood

Blood tests
Blood tests check for:
- High or low white blood cell count (caused by infection)
- Low platelet level (caused by poison released by bacteria)
- High level of acid in the blood (caused by dying tissue)
X-rays to check for signs of NEC
Your child may need X-rays of their belly and chest to look for these signs of NEC:
- Pockets of air inside the wall of the bowels
- Air bubbles in the vein from the bowels to the liver
- Air inside the belly but outside the bowels
- Fluid inside the belly
- Enlarged loops of bowels that do not move

Treating NEC Without Surgery

Your child’s treatment will depend on how serious their illness is. Your baby may not need surgery unless there are signs that part of their bowels has died or has holes.

We will place a tube through your baby’s nose to their stomach. This is called a nasogastric tube or NG tube. The NG tube prevents their stomach and bowels from filling with air. Your baby will keep the NG tube until all signs show their bowels have healed and are ready to handle regular feedings.

Your baby will get intravenous (IV) fluids to prevent dehydration and give them nutrients. The fluids also help keep their blood chemicals and blood pressure normal.

We give your baby IVantibiotics to fight infection. Most babies with NEC need antibiotics for 10 days to 14 days. During this time, your baby will get all their nutrition directly into the bloodstream through an IV line. This lets their bowels rest and heal.

Some babies need medicine to help support their blood pressure. Keeping your baby’s blood pressure normal helps their intestines get good blood flow.

The doctor will use X-rays and blood tests to check your baby’s health during treatment.

Surgery for NEC

If there are signs that any part of your baby’s bowels has died or has holes (perforated), your baby will need surgery to remove that part. The goal of surgery is to remove only the dead or perforated part, leaving as much as possible. Even if part of the bowels that’s left is inflamed or infected, it might heal. Your baby is likely to grow and develop better if they keep more of their bowels.

Before surgery, the surgeon and a doctor who specializes in newborns (neonatologist) will try to make your baby’s condition stable. Your baby will need the same treatments as babies who are not having surgery. These include an NG tube, IV fluids and antibiotics.

During surgery
If your baby needs surgery, we will give them medicine to make them sleep without pain (general anesthesia). The doctors at Seattle Children’s have extra years of training in how to give anesthesia to children safely.

The surgeon makes a cut (incision), usually above the belly button, to open the belly. Then the surgeon cuts out any segment of bowel that is dead.

The surgeon may leave parts of the bowels that are sick but not dead so your baby has as much as possible. Your baby may have another surgery within 2 days to see if those parts will survive or need to be removed.

When surgeons have to cut out part of the bowels, they may use stitches to reconnect the bowels. This is called primary anastomosis (pronounced an-as-toe-MOE-sis). It is possible only if:
- A small segment was removed
- The rest of the bowels seems healthy
- Your baby is in good condition
Ostomy

If the rest of the bowels do not seem healthy or a large part was removed, the surgeon might not reconnect the bowels. Instead, the surgeon creates 2 small openings (stoma) in your baby’s belly wall. This procedure is called an ostomy (pronounced OST-uh-mee).

The surgeon sews the upper end of the bowels to 1 opening in the belly. This lets bowel movements (poop) come out of the body into a plastic pouch attached on the outside of the body. Next, the surgeon sews the lower end of the bowels to the other opening. This end is called the mucus fistula. Usually very little comes out of this opening.

If your baby needs ostomies, we will teach you how to care for the openings. These ostomies are temporary. When your baby is doing better, the surgeon will connect the 2 segments of the bowels to each other and close the openings in your baby’s belly. Usually this is done at least 2 months later and when your baby is growing well.
Strictures
As NEC heals, a scar may form that makes the bowels very narrow. This is called a stricture. It can happen:
- Where the surgeon sewed the 2 ends of the bowels together
- In areas of the bowels that had NEC and didn’t need surgery
Most often if a stricture forms, surgery is needed to fix it.
Short bowel syndrome

If your child had a large part of their bowels removed, the remaining part may not absorb nutrients from food properly. This is called short bowel syndrome. It can cause serious problems with your child’s growth and development. Our team keeps as much of your child’s bowels as possible to try to prevent this.
After surgery
After surgery, your baby will continue to receive the highest level of care in our Level IV Neonatal Intensive Care Unit (NICU).

When your baby is ready, they move to a regular hospital room. We give your baby antibiotics, pain medicine and other medicines to help them recover.

The surgery and newborn care teams will stay closely involved with your baby’s care. As your baby starts to feed again, the neonatology staff will take over all your baby’s care.

The surgeon will see your baby again if:
- The ostomies need to be closed
- There are problems with short bowel syndrome
- There are any other issues that relate to surgery

Feeding and Nutrition

Whether or not your child has surgery, they will get feedings through a tube that goes into a large vein (central line). This nourishment goes into the bloodstream and bypasses the stomach and bowels. When they have recovered from NEC, some babies need a tube from their nose (NG tube) or mouth (orogastric or OG tube) to their stomach.

Our nurses and lactation specialists will do everything we can to support you in providing breastmilk for your baby. To keep your milk flowing and to build a milk supply for your baby, we help you with breast pumping and storing your milk. When your baby is ready, our nurses and feeding therapists help with the transition to feeding by bottle or breast.

Our nutritionists are important members of your child’s team. They keep a close check to be sure your baby is growing well. They adjust your baby’s IV nutrition and advise on feeding by mouth.

If a large part of their bowels was removed, your baby may develop short bowel syndrome. The team at our Intestinal Rehabilitation Program focuses on getting your child’s bowels working again so they get the nutrition they need to thrive. It is the only program of its kind in the Pacific Northwest and 1 of just a few in the nation.

Going Home and Follow-Up Care

How long your baby will stay in the hospital depends on how NEC affected their bowels. Premature babies often have other health problems and need hospital care after they have healed from NEC.

When some babies go home, they need medicine or a feeding tube in their nose (NG tube) for part of their nutrition. Our nurses will help set up any supplies and equipment you need. You will have plenty of time to practice all your baby’s care before going home.

If your child has short bowel syndrome, our Intestinal Rehabilitation Program provides follow-up care to keep them healthy over the long term. Usually we see children in the hospital campus in Seattle. Some long-term follow-up is offered at our clinics in Bellevue, Everett, Federal Way and Tri-Cities.