Patient handout

Necrotizing enterocolitis (NEC) — neonatal / preterm Bell-staged

PRODUCTION

1. Your condition

This handout is for necrotizing enterocolitis (nec) — neonatal / preterm bell-staged. Your care team identified this based on: preterm neonate with feeding intolerance (residuals, emesis), abdominal distention, occult/bloody stools (walsh & kliegman 1986; aap nec guidance).

Other reasons your team may use this plan: preterm neonate with abdominal wall erythema / induration / palpable mass — advanced nec (stage iib+) features; preterm neonate with declining platelets + metabolic acidosis (stage iib criteria; walsh & kliegman 1986); pneumatosis intestinalis on kub — pathognomonic of definite nec (stage iia+) (walsh & kliegman 1986; lr+ ~ 50).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
ampicillin	200 mg/kg/day divided q8h (DOL 0-7) or q6h (DOL > 7); meningitis dose: 300 mg/kg/day divided q6-8h	IV	q6-8h	Covers Gram-positive (including Listeria) + sensitive E. coli baseline; standard NEC empiric (AAP NEC guidance)
gentamicin	Term ≥ 35 wk: 4 mg/kg q24h; late-preterm 30-34 wk: 4.5 mg/kg q36h; preterm < 30 wk: 5 mg/kg q48h (extended interval per gestational age)	IV	q24-48h extended interval	Gram-negative synergy with ampicillin; extended-interval dosing per Neofax + AAP Puopolo 2018; trough monitoring before 3rd dose
metronidazole	15 mg/kg load then 7.5 mg/kg q12h (DOL > 7) or q24h (DOL < 7)	IV	q12-24h	Anaerobic cover for confirmed NEC (Stage II+) where bowel-wall integrity is compromised; alternative pip-tazo combined regimen if preferred
piperacillin-tazobactam	80-100 mg/kg/dose (piperacillin component) IV q6-8h (gestational + chronological-age dependent)	IV	q6-8h	Anaerobe + Pseudomonas + enteric Gram-negative cover; alternative to ampicillin + gentamicin + metronidazole combo; single agent simplifies regimen
vancomycin	15 mg/kg/dose IV; interval per gestational + chronological age (q6h-q18h)	IV	per nomogram	Add-on for MRSA / CoNS / line-associated sepsis coinfection; AUC target 400-600 (Rybak IDSA 2020) with caveat — limited neonatal data

Plan: NEC empiric antibiotics — by Bell stage + comorbidity (Walsh & Kliegman 1986; AAP NEC guidance; Cantey 2018 stewardship)

3. When to call your provider

Contact your care team if any of the following happen:

New abdominal distention + bilious emesis + feeding intolerance post-recovery → urgent peds-GI + peds-surgery + contrast study for stricture
New fever > 38 °C OR recurrent symptoms within 4 weeks of discharge → return to ED, blood culture, source-directed workup
New focal neurological signs OR seizures → urgent neuro + neuroimaging
Hearing loss confirmed on audiology → ENT + audiology + speech + early intervention
TPN-associated cholestasis worsening (direct bilirubin > 2 sustained) → lipid strategy modification + intestinal transplant evaluation
Family caregiver PHQ-9 ≥ 15 OR EPDS elevated → mental-health urgent referral
Suspected immunodeficiency (≥ 2 serious infections in 12 mo OR unusual pathogen recurrence) → clinical immunology referral

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Bell Stage IIIB — pneumoperitoneum on KUB (free air under diaphragm, football sign, Rigler sign) — life-threatening surgical emergency requiring emergent pediatric-surgery evaluation: peritoneal drain in extremely preterm < 1000 g vs laparotomy in larger; surgical resection of necrotic bowel ± ostomy formation; ICU + max support (Walsh & Kliegman 1986; AAP NEC guidance)(life-threatening)
Bell Stage IIIA — advanced NEC without overt perforation: ventilator-dependent + hypotension + bradycardia + severe apnoea + DIC + neutropenia — life-threatening systemic involvement; surgical readiness; aggressive antibiotic + supportive care; possible bowel resection without overt perforation (Walsh & Kliegman 1986; AAP NEC guidance)(life-threatening)
Bell Stage IIA or IIB — definite NEC with pneumatosis intestinalis on KUB (pathognomonic; LR+ ~ 50 for NEC). IIB adds metabolic acidosis + thrombocytopenia. Severe; full antibiotic course (7-10 d) + NPO 7-14 d + serial KUB + nutrition planning + surgical-readiness in IIB (Walsh & Kliegman 1986; AAP NEC guidance)
Portal venous gas on KUB or abdominal US (LR+ ~ 20 for NEC) — relative surgical indication; high mortality if delayed surgical evaluation; consider exploration even without overt free air (Pediatric Radiology imaging literature)
NEC in term or late-preterm infant (≥ 32 wk) is atypical (~ 0.1% of NICU admissions vs ~ 7-10% in VLBW) — consider underlying anomaly: malrotation/volvulus (upper-GI series), congenital heart disease with mesenteric ischemia (echo + cardiology), sepsis with bacterial translocation (full sepsis workup), Hirschsprung-associated enterocolitis (history of delayed meconium passage). Broader differential workup beyond standard preterm-NEC pathway
Recurrent NEC after initial antibiotic course + Bell-staging resolution — repeat workup with KUB + abdominal exam + CBC + CRP + blood culture; consider stricture (~ 10-30% after Stage II-III medical), missed perforation, or post-NEC mucosal injury; long-term peds-GI + peds-surgery follow-up
Extensive surgical resection (> 50% small bowel) + early TPN-dependence → short bowel syndrome emerging → nutrition consult + central venous access + long-term IFALD prevention (lipid strategy modification, minimise TPN duration, advance enteral feeds early); intestinal transplant evaluation if non-rehabilitatable (Pichler 2014; ASPEN guidelines)
Feeding intolerance + abdominal distention + bilious emesis post-recovery from Stage II-III medical NEC — stricture incidence ~ 10-30%; contrast study (upper-GI or lower-GI per location) + peds-GI + peds-surgery → surgical resection of stricture (Pediatric Surgery NEC-stricture literature)

5. Follow-up

Outpatient peds within 24-48 h of discharge for high-risk; 1-week visit for all; growth + feeding tracking + developmental milestones; peds-GI surveillance for stricture (~ 10-30% after Stage II-III medical; symptoms — feeding intolerance, distention, emesis post-recovery; contrast study + surgical resection if symptomatic stricture); peds-surgery follow-up for post-op (ostomy management, takedown timing); nutrition follow-up for SBS / IFALD if extensive resection (TPN management, lipid strategy, central line care, intestinal transplant evaluation if non-rehabilitatable); neurodevelopmental peds at 6 + 12 + 24 mo (Bayley III / ASQ-3 — preterm + NEC survivors at elevated risk); immunization catch-up per cause (PCV / Hib + hepatitis B); hearing screen if meningitis precipitant. Family education on return precautions; vaccination of family contacts (Tdap, influenza, COVID-19); breastfeeding support.

6. Sources

Guideline: Walsh & Kliegman 1986 Modified Bell Staging (Pediatr Clin North Am) + Bell 1978 original (Ann Surg) + AAP Section on Neonatal-Perinatal Medicine + Section on Surgery NEC clinical guidance + JNPM 2024 NEC update + Cantey 2018 antibiotic stewardship (PMID 30172430) + IDSA candidiasis 2016 (Pappas) + IDSA CRBSI 2009 (Mermel) + IDSA intra-abdominal 2010 (Solomkin) + Quigley & McGuire Cochrane 2019 (human milk vs formula) + Pammi & Suresh Cochrane 2020 (lactoferrin) + Gordon 2007 SIP-vs-NEC + Pediatric Surgery 2024 SIP-vs-NEC consensus