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Modified Bell´s Staging Criteria for Necrotizing Enterocolitis (NEC)


Systemic signs

Abdominal signs

Radiographic signs



Temperature instability, apnea, bradycardia, lethargy

Gastric retention, abdominal distention, emesis, heme-positive stool

Normal or intestinal dilation, mild ileus

NPO, antibiotics x 3 days


Same as above

Grossly bloody stool

Same as above

Same as IA

Definite, mildly ill

Same as above

Same as above, plus absent bowel sounds with or without abdominal tenderness

Intestinal dilation, ileus, pneumatosis intestinalis

NPO, antibiotics x 7 to 10 days

Definite, moderately ill

Same as above, plus mild metabolic acidosis and thrombocytopenia

Same as above, plus absent bowel sounds, definite tenderness, with or without abdominal cellulitis or right lower quadrant mass

Same as IIA, plus ascites

NPO, antibiotics x 14 days

Advanced, severely ill, intact bowel

Same as IIB, plus hypotension, bradycardia, severe apnea, combined respiratory and metabolic acidosis, DIC, and neutropenia

Same as above, plus signs of peritonitis, marked tenderness, and abdominal distention

Same as IIA, plus ascites

NPO, antibiotics x 14 days, fluid resuscitation, inotropic support, ventilator therapy, paracentesis

Advanced, severely ill, perforated bowel

Same as IIIA

Same as IIIA

Same as above, plus pneumoperitoneum

Same as IIA, plus surgery

DIC: disseminated intravascular coagulation

NPO: “nil per os” or nothing by mouth


Related Criteria

Rochester Criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection

Causes of Bacteraemia and Meningitis in Young Children

Clinical and Laboratory "Low Risk" Criteria for Children Younger Than 3 Months with Fever and No Focus of Infection

Diagnostic Criteria for Cystic Fibrosis (CF)

Definition and Causes of Apparent Life-Threatening Events (ALTE)



  1. Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am. 1996 Apr;43(2):409-32. [Medline]

  2. Caplan MS, Jilling T. New concepts in necrotizing enterocolitis. Curr Opin Pediatr. 2001 Apr;13(2):111-5. [Medline]

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Created: May 25, 2006
Last Modified: 10/23/2010

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