Necrotizing Enterocolitis

Necrotizing enterocolitis remains incompletely understood despite six decades of research, with no clear predictors of which infants will require surgery. Probiotics are the only preventive strategy with Cochrane-level evidence, yet most U.S. institutions do not routinely use them due to formulation and dosing uncertainty. Feeding rate does not correlate with NEC development. Pneumoperitoneum is the sole absolute surgical indication; otherwise, a constellation of findings—pneumatosis, hemodynamic instability, fixed loops, worsening acidosis—guides operative timing. Focal abdominal wall erythema is highly sensitive for underlying necrosis. The NEST and MOSS trials showed no mortality difference between peritoneal drainage and laparotomy in extremely low birth weight infants, though emerging data suggest laparotomy may confer better neurodevelopmental outcomes. Primary anastomosis at initial operation remains uncommon in the U.S. (8–10%), but the STAT trial demonstrated significantly shorter parenteral nutrition duration without increased mortality or unplanned reoperations. Stoma takedown is typically performed at 4–6 weeks and 2 kg, though recent data support earlier reversal. Ultrasound is emerging as a superior diagnostic modality, detecting bowel wall thinning, perfusion abnormalities, and fluid collections missed by plain radiography (sensitivity 13–25%). In ultra-short gut (<20 cm), current-era survival exceeds 90%, with most patients achieving enteral autonomy and normal neurodevelopment.