Unifying Concepts

Diagnostic Criteria for Necrotizing Enterocolitis (NEC)

Necrotizing enterocolitis is among the most common and devastating diseases in neonates. The excessive inflammatory process initiated in the highly immunoreactive intestine in necrotizing enterocolitis extends the effects of the disease systemically, affecting distant organs such as the brain and placing affected infants at substantially increased risk for neurodevelopmental delays.

Diagnostic Criteria for Necrotizing Enterocolitis (NEC)
Suspected necrotizing enterocolitis

  • Abdominal distention without radiographic evidence of pneumatosis intestinalis, portal venous gas, or free intraperitoneal air
  • Unexpected onset of feeding intolerance

Definitive medical necrotizing enterocolitis

  • Abdominal distention with pneumatosis intestinalis, portal venous gas, or both
  • Other radiographic signs such as fixed, dilated loops of intestine and ileus patterns are not pathognomonic but should be treated as such

Surgical necrotizing enterocolitis

  • Free intraperitoneal air on abdominal radiograph after initial medical signs and symptoms
  • Persistent ileus pattern, abdominal distention, and radiographs that show an absence of bowel gas, coupled with deteriorating clinical and laboratory values (e.g., decreasing neutrophil and platelet counts)

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


  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]

  3. Neu J, Walker WA. Necrotizing Enterocolitis. N Engl J Med 2011; 364:255-264 [Medline]
Created: May 25, 2006
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