A premature infant boy has been started on enteral feeds shortly after birth, but develops feeding intolerance 2 weeks postnatally. He displays abdominal tenderness, distention, and bloody stools. An abdominal radiograph is obtained and is shown in Fig. below. What should be the next step in management?
a. Nasogastric decompression, parenteral nutrition, broadspectrum antibiotics
The radiograph demonstrates pneumatosis intestinalis, in conjunction with the clinical scenario described, describes Bell stage II necrotizing enterocolitis (NEC). In all infants suspected of having NEC, feedings are discontinued, a nasagastric tube is placed, total parenteral nutrition (TPN) is started, and broad-spectrum parenteral antibiotics are given. The infant is resuscitated, and inotropes are administered to maintain perfusion as needed. Intubation and mechanical ventilation may be required to maintain oxygenation. Subsequent treatment may be influenced by the particular stage of NEC that is present. Patients with Bell stage II disease merit close observation. Serial physical examinations are performed looking for the development of diffuse peritonitis, a fixed mass, progressive abdominal wall cellulitis, or systemic sepsis. If infants fail to improve after several days of treatment or if abdominal radiographs show a fixed intestinal loop, consideration should be given to exploratory laparotomy.
Abdominal radiograph of infant with necrotizing enterocolitis. Arrows point to area of pneumatosis intestinalis.