Necrotizing Enterocolitis

Necrotizing enterocolitis remains incompletely understood despite six decades of research, with no definitive cure and no clear predictive factors for surgical progression. Preventive strategies center on probiotics, which have Cochrane-level evidence for reducing incidence, though U.S. adoption remains inconsistent due to formulation uncertainty. Acid suppression should be avoided, as PPIs and H2 blockers increase NEC risk. Surgical indications include pneumoperitoneum (absolute), clinical deterioration despite maximal medical therapy, and focal abdominal wall erythema (highly sensitive for necrosis). The MOSS and PIERO trials showed equivalent mortality between peritoneal drainage and laparotomy, but emerging data suggest laparotomy may confer better long-term neurodevelopmental outcomes. The NEST trial (300 patients) will report 18–22-month neurologic assessments within 1–2 years. The recent STAT trial demonstrated that primary anastomosis—when hemodynamically feasible—reduces parenteral nutrition duration without increasing mortality or unplanned reoperations, challenging traditional stoma-first dogma. Post-NEC strictures occur in ~19% of medically managed cases, typically in the colon near the splenic flexure; contrast enema detects 92% and is indicated primarily after NEC (not SIP). Ultrasound is emerging as a superior early diagnostic modality (X-ray sensitivity 13–25%), identifying bowel wall thinning, perfusion defects, and occult fluid collections, though standardized protocols and training remain barriers.