Digestive and Gastrointestinal Conditions

Necrotizing Enterocolitis

What is necrotizing enterocolitis?

Necrotizing enterocolitis (NEC) is a problem with the intestines.

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

With NEC the intestines get irritated and infected by bacteria. The infection can cause part of the intestine to die.

In babies born early (prematurely), NEC most often affects the last part of the small intestine (ileum) or the large intestine (colon). NEC may affect just 1 segment of intestine or more than 1 segment. In the worst cases, it affects the whole intestine.

NEC can range from mild to life threatening. In milder cases, the intestines may heal and be fine if the baby gets medical treatment, including antibiotics to fight the infection. In more serious cases, the baby may need surgery to remove damaged intestine, or the infection may overwhelm the baby’s body.

  • Premature babies are more likely to get NEC. It can happen in babies who are not born early (carried to term), but this is rare. Some infants with other health problems, such as gastroschisis, may also get NEC. The cause of NEC is not clear. Each of these factors seems to play a role:

    • The baby’s intestines may not be mature enough to move food along well when the baby is fed. This may cause their intestines to get irritated and swollen (inflamed). Some studies show that NEC happens mostly in premature babies who have been fed (rather than getting nutrition by an intravenous (IV) line). Other studies suggest that early feeding of premature infants may actually protect against problems like NEC. The studies are controversial. There is good evidence to support both early feeding of premature babies and using only IV nutrition.
    • Bacteria in the baby’s intestines reproduce. The baby’s immune system is not able to protect the intestines from the bacteria. The intestines get infected.
    • The baby’s immune system overreacts to the infection. The intestines get more inflamed. Blisters may form inside the intestines.
    • Blood flow to the baby’s intestines is poor. The bacteria may cause this. Without good blood flow, the tissue can be damaged and die. Dead tissue may get holes (perforate). Then stool (feces) and bacteria can leak from the intestines into the belly and cause infection there (peritonitis).

Necrotizing Enterocolitis at Seattle Children’s

We have treated hundreds of babies with NEC at Seattle Children’s. Our goal is to treat this condition without surgery whenever we can. Most babies with NEC (about 70%) can be treated without surgery.

We generally see more than 20 babies each year who need surgery for NEC. Our surgeons are experienced at doing the surgeries needed to remove damaged intestine while leaving as much intestine as possible.

  • When you come to Seattle Children’s, you have a team of people to care for your child before, during and after surgery. Along with your child’s surgeon, you are connected with nurses, dietitians, child life specialists and others. We work together to meet all of your child’s health needs and help your family through this experience.

    We work with children and families from around the Northwest and beyond. Whether you live nearby or far away, we can help with financial counseling, schooling, housing, transportation, interpreter services and spiritual care. Learn about our services for patients and families.

Symptoms of Necrotizing Enterocolitis

Babies with necrotizing enterocolitis (NEC) may have these symptoms:

  • Green vomit (also called bilious because it contains bile, a liquid made in the liver to help digest fats)
  • Diarrhea or bloody stools (feces)
  • Swollen belly (abdomen)
  • Red or blue color in the belly
  • Tiredness, sluggishness or no energy (lethargy)
  • Problems keeping a normal body temperature
  • Breathing problems
  • Slow heart rate

Diagnosing Necrotizing Enterocolitis

If your child has symptoms of NEC, your child’s doctor will go over a detailed history of your child’s illness. The doctor will do a thorough exam and may do blood tests to check for:

  • High or low white blood cell level (caused by infection)
  • Low platelet level (caused by poison released by bacteria)
  • High level of acid in the blood (caused by dying tissue)
  • The doctor may also check your child’s stool for blood.

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 intestine (pneumatosis intestinalis, caused by bacteria)
  • Air bubbles in the vein from the intestines to the liver (portal vein gas, caused when the blood absorbs air that built up in the wall of the intestines)
  • Air inside the belly but outside the intestines (pneumoperitoneum, caused when the intestines get holes and air leaks out)
  • Fluid inside the belly (ascites, caused when the intestines get holes and fluid leaks out)
  • Enlarged loops of intestine that do not move (which may mean that part of the intestine has died)

Treating Necrotizing Enterocolitis

In milder cases of necrotizing enterocolitis (NEC), the baby’s intestines may heal if the baby gets medical treatment. In more serious cases, the baby may need surgery to remove damaged intestine.

  • If there’s no sign that your baby’s intestine has died or has holes (perforated), your baby may not need surgery.

    Your baby will need a NG tube (also called a nasogastric tube), which goes through their nose to their stomach. The NG tube will suction air out of their stomach and intestines. Your baby will keep the NG tube until all signs suggest their intestines have healed and are ready to handle feedings with formula.

    Your baby will need IV (intravenous) fluids to prevent dehydration, keep their blood chemicals normal and give them nutrients. Your baby will also get IV antibiotics to fight infection. In most cases, babies with NEC need antibiotics for 10 days to 2 weeks. During this time, your baby will not be fed so their bowel can rest and heal. Instead, your baby will get IV nutrition.

    It’s important to keep your baby’s blood pressure normal to make sure their intestines get good blood flow. IV fluids will help with this. Some babies need medicine to help support the blood pressure.

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

  • If there are signs that any segment of your baby’s intestine has died or perforated, your baby will need surgery to remove that segment. The goals of surgery are to remove only the dead or perforated segment and to leave as much as possible. Even if some of the intestine that’s left is inflamed or infected, it might heal. Your baby is likely to grow and develop better if they have more intestine left.

    Before the 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 aren’t having surgery. For example, your baby will need an NG tube, IV fluids and antibiotics.

  • At the time of surgery, we will give your child medicine (general anesthesia) to make them sleep without pain. The doctors at Seattle Children’s who give your child anesthesia are board certified in pediatric anesthesiology. This means they 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 enter the abdomen. Then the surgeon cuts on each side of any segment of bowel that is dead and takes it out.

    Some of the intestine may be sick but not dead. The surgeon may leave this part because it is important for your baby to have as much intestine as possible. Then your baby may have another surgery within 24 to 48 hours to see if the intestine will survive or needs to be removed.

    When surgeons have to cut out a segment of intestine, they may sew together the 2 open ends of the intestine (primary anastomosis, pronounced an-as-toe-MOE-sis). This may be possible if only a small segment was removed, the rest of the intestine seems healthy and your baby is in good condition.

  • If a large segment was removed or the rest of the intestines do not seem healthy, the surgeon might not connect the 2 open ends. Instead, the surgeon creates 2 small openings (stoma) in your baby’s belly. (This procedure is called an ostomy, pronounced OST-uh-mee.) The surgeon sews the upper end of the intestine to 1 opening. This lets bowel movements come out of the body into a plastic pouch attached on the outside. Next, the surgeon sews the lower end of the intestine to the other opening. This end is called the mucus fistula. Usually very little comes out of the mucus fistula.

    If your baby needs ostomies, you will get instructions about how to care for the openings. Later, after your baby is doing better, the surgeon will connect the 2 ends of the intestine and close the openings in your baby’s belly. Usually this is done at least 2 months later and when the baby is growing well.

  • As NEC heals, a stricture may form in the intestine. A stricture is a scar that makes the intestine very narrow. This can happen where the surgeon sewed the 2 ends of the intestine together. It can also happen in areas of the intestine that had NEC and didn’t need surgery. Usually if a stricture forms, the baby needs surgery to fix it.

  • If your baby needs a large segment of intestine removed, they may be at risk for short bowel syndrome. The surgeon will keep as much intestine as possible to try to prevent this.

  • After surgery, your baby goes to our Level IV Neonatal Intensive Care Unit (NICU), where they get the high level of care they need.

    When your baby is ready, they move to a regular hospital room and, eventually, home. Your baby gets the antibiotics, pain medicine and other medicines needed to help them recover.

    Babies who have NEC may need to stay in the hospital for weeks or even months, whether they had surgery or not. Most often their long stay is due to other health issues linked to being born early (prematurely) rather than to NEC alone.

    All babies with NEC get feedings through a tube that goes into a large vein (central line). When they have recovered from NEC, some of them will have a tube that passes through the nose or mouth into the stomach (nasogastric tube, NG tube; or orogastric tube, OG tube).

    The surgery and neonatology staff will stay closely involved with your baby’s care. As your baby starts to feed again, your baby will need less care from the surgeon, and neonatology staff will take over all of the care. The surgeon will see your baby again if the ostomies need to be closed, if there are problems with short bowel syndrome or if there are any other issues that relate to surgery.

Contact Us

If you have questions about necrotizing enterocolitis treatment, call our General and Thoracic Surgery Department at 206-987-2794. If you would like an appointment, ask your child’s primary care provider for a referral.

Providers, see how to refer a patient.