**8. Differential diagnosis**

Blood stream infection can present like NEC and must be ruled out. Sepsis and other conditions that can cause feeding intolerance, rectal bleeding, abdominal distension, gastric retention of feed, or intestinal perforation can be differentiated from NEC by the absence of radiologic evidence of pneumatosis intestinalis and the characteristic combination of rectal bleeding presenting as heme-positive or grossly bloody stools, abdominal distention, bilious vomiting, and gastric aspirates as seen in NEC. Spontaneous intestinal perforation is characterized by a single noninflammatory perforation that is typically located at the terminal ileum or colon. It occurs primarily in infants with birth weight <1000 g and is differentiated from NEC by the presence of less severe systemic signs and absence of pneumatosis intestinalis. Infectious enteritis may present with frequent, occasionally bloody stools with abdominal distension but no pneumatosis. Congenital anomalies of GIT, such as Hirschsprung disease, small bowel atresia, meconium ileus, and acquired conditions like volvulus and intussusception, present with intestinal obstruction and at times secondary enterocolitis. Abdominal radiography differentiates these conditions from NEC. Anal fissures can result in rectal bleeding and can be detected on pertinent thorough physical examination. Milk protein allergy-induced enterocolitis may present with heme-positive stools and other GI symptoms similar to NEC in preterm infants but no pneumatosis. Such patients respond to dietary modification by switching the formula to extensively hydrolyzed or amino acid-based ones and may have eosinophilia along with thrombocytosis.

**35**

**Table 4.**

**NEC Bell's stage**

**Treatment**

1a and 1b Antibiotics × 3 days, NPO 2a NPO, antibiotics × 7–10 days 2b NPO, antibiotics × 14 days

3b As in 3a plus surgery

*Management principles of NEC [65].*

*Necrotizing Enterocolitis*

**9. Management**

**9.1 Medical management**

*DOI: http://dx.doi.org/10.5772/intechopen.85784*

provided during the period that the infant is nil by mouth.

The basic principles of management of NEC are bowel decompression and rest, antibiotics coverage, cardiorespiratory support, fluid resuscitation, provision of blood products, and surgical intervention if indicated. The management strategies according to Bell's staging are outlined in **Table 4**. Surgical consultation is obtained in all stages of NEC including stage 1. Total parenteral nutrition (TPN) should be

The principles are as follows: (1) bowel decompression and rest, (2) parenteral hydration and nutrition, (3) respiratory and cardiovascular support, (4) antibiotic therapy, (5) general supportive care, (6) fluid resuscitation, and (7) serial close laboratory monitoring and radiologic surveillance. The focus is on limiting the progression of the disease. Intermittent or continuous nasogastric suction is done for bowel decompression, TPN is provided to ensure nutrition, and fluid is replaced to correct third space losses. Adequate cardiorespiratory support is of paramount value, and hematologic anomalies, such as DIC, anemia, and thrombocytopenia, are promptly corrected. Metabolic abnormalities, such as metabolic acidosis, hyponatremia, and hyper- or hypoglycemia, are appropriately treated. Even though an infectious agent has not been identified or attributed to NEC, antibiotics are routinely used in its treatment. Observational data reveal that 20–30% cases of NEC have bacteremia, and pathogenic bacteria are recovered from pathologic specimens and peritoneal fluid. Epidemic outbreaks of NEC are common, and the clinical picture improves with antibiotics. The efficacy of antibiotic agents is documented in experimental animal models for NEC. The commonly used empiric broad-spectrum antibiotic combinations are as follows: ampicillin gentamicin (or amikacin), ampicillin, gentamicin (or amikacin) and clindamycin or ampicillin, cefotaxime, and metronidazole. Ceftazidime is an alternative choice for cefotaxime. Other antibiotic combinations are tazobactam and gentamicin (or amikacin); vancomycin, piperacillin-tazobactam, and gentamicin; and meropenem and vancomycin if methicillin-resistant staphylococcus or ampicillin-resistant enterococcus infections are suspected. Amikacin may be used in centers with significant gentamicin resistance. Metronidazole or clindamycin is added to cover anaerobic bacteria, especially in cases where infant is fed orally before NEC supervenes.

Evaluation of progression of the disease is important in order to take appropriate and timely steps to avoid further damage to the bowel. Serial laboratory monitoring is routinely performed. At diagnosis stool for guaiac test, complete blood and differential neutrophil counts, blood culture, CSF study if indicated, C-reactive protein, platelet count, serum electrolytes, pH, creatinine, blood urea nitrogen, and acid-base studies are obtained and monitored q 12 or 24 h or more frequently

3a As in 2b plus, fluid resuscitation, inotropic and ventilator support, blood products
