Paeds Cases · fetal-neonatal-and-perinatal
The deteriorating preterm — suspected necrotising enterocolitis
OSCE on a preterm infant with established NEC, testing modified Bell staging, the medical bundle, the surgical trigger, the primary peritoneal drainage versus laparotomy decision, and the prevention bundle — with a contrast branch to spontaneous intestinal perforation.
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Prompt
A 26-week, 780 g infant, day 9 of life on formula feeds, develops bilious gastric residuals, a distended and tender abdomen, apnoeic spells, and a falling platelet count; the abdominal radiograph shows pneumatosis intestinalis and portal venous gas. The candidate must recognise Stage IIB NEC, give the medical bundle, identify the surgical trigger, choose between primary peritoneal drainage and laparotomy, and contrast the picture with spontaneous intestinal perforation.
Clinical information for the examiner
Setting: Tertiary NICU, day 9 of life. The infant was born at 26 weeks to a mother who received one dose of antenatal corticosteroid; one dose of surfactant was given at birth for respiratory distress syndrome. Feeds were advanced on formula to 120 mL/kg/day by day 8. [1]
On your arrival:
- Heart rate 168 (was 150), respiratory rate 65 with increased work, SpO₂ 88% in air. [3]
- Temperature 36.9°C but capillary refill 4 seconds; blood pressure 38/24 (mean 28). [1]
- Abdomen is distended and tender, with mild erythema of the lower abdominal wall; bowel sounds are absent. A nasogastric tube is draining 28 mL of bilious fluid. [3]
- Recent bloods: platelets 90 × 10⁹/L (was 220), CRP 42, base excess −8. [1]
- Abdominal radiograph: pneumatosis intestinalis in the terminal ileum and portal venous gas over the liver; no free air. [3]
References7ShowHide
- [1]Bell MJ Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg, 1978.PMID 413500
- [2]Walsh MC Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am, 1986.PMID 3081865
- [3]Neu J Necrotizing enterocolitis. N Engl J Med, 2011.PMID 21247316
- [4]Rees CM Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial. Ann Surg, 2008.PMID 18580206
- [7]Swanson JR Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight infant. J Perinatol, 2022.PMID 35177793
- [11]Attridge JT New insights into spontaneous intestinal perforation using a national data set (3): antenatal steroids have no adverse association with spontaneous intestinal perforation. J Perinatol, 2006.PMID 17024144
- [13]Bethell GS Surgeons and neonatologists views about surgical decision-making in necrotising enterocolitis. Arch Dis Child Fetal Neonatal Ed, 2025.PMID 40280739