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Necrotizing enterocolitis following spontaneous intestinal perforation in very low birth weight neonates

Journal of Perinatology volume 45, pages 642–649 (2025)Cite this article

Subjects

Abstract

Purpose

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are severe gastrointestinal complications of prematurity. The clinical presentation and treatment of NEC and SIP (peritoneal drain vs laparotomy) can overlap; however, the pathogenesis is distinct. Therefore, a patient initially treated for SIP can subsequently develop NEC. This phenomenon has only been described in case reports, and no risk factor evaluation exists. We evaluate clinical characteristics, risk factors, and outcomes of patients treated for a distinct episode of NEC after SIP.

Methods

We performed a retrospective review of very low birth weight (<1500 g) neonates who presented with pneumoperitoneum between 07/2004 and 09/2022. Data was obtained from two separate neonatal intensive care units that were part of the same institution. Patients with an initial preoperative, intraoperative, or pathological diagnosis of NEC were excluded. Patients with an intraoperative diagnosis of SIP or preoperative diagnosis of SIP successfully treated with a peritoneal drain (PD) were evaluated. Patients subsequently treated (medically or surgically) for NEC after SIP were then compared to SIP-alone patients. Clinical characteristics included demographics, gestational age (GA), birth weight (BW), perinatal risk factors (chorioamnionitis, steroids, indomethacin), postoperative feeding regimen, and length of stay (LOS) were compared.

Results

Of the 278 patients included, 31 (11.2%) patients had NEC after SIP. There was no difference in GA (25 weeks vs 25 weeks, p = 0.933) or BW (760 g vs 735 g, p = 0.370) between NEC after SIP vs SIP alone cohorts, respectively. Twenty (64%) of NEC after-SIP patients were previously treated with LP. NEC after SIP occurred with a median onset of 56 days. Pneumatosis was the most frequent (81%) presenting symptom and 12 (39%) patients had hematochezia. Four (12.9%) patients required LP for NEC and all had NEC intraoperatively and on pathology. A majority (77.4%) of patients were on breast milk (BM) at time of NEC diagnosis. NEC after SIP patients had lower maternal age at delivery (29.0 vs 25.0, p = 0.055) and the incidence of NEC after LP (primary or failed drain) was higher than PD alone (16.7% vs 6.2%, p = 0.007). NEC after SIP patients had longer LOS (135 vs 81, p < 0.001).

Conclusion

We report an 11.2% incidence of NEC at a median of 56 days following successful treatment of SIP, resulting in increased LOS. SIP patients are a high-risk cohort and protocols to prevent this phenomenon should be investigated.

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Author information

Authors and Affiliations

  1. Department of Surgery, Emory University, Atlanta, GA, USA

    Goeto Dantes & Olivia A. Keane

  2. Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Swathi Raikot & Amina M. Bhatia

  3. Emory University School of Medicine, Emory University, Atlanta, GA, USA

    Louis Do & Savanah Rumbika

  4. Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA

    Zhulin He

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  1. Goeto Dantes
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  2. Olivia A. Keane
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  3. Swathi Raikot
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  4. Louis Do
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  5. Savanah Rumbika
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  7. Amina M. Bhatia
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Contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by GD, OK, LD, and SR. Data analysis was performed by ZH. The first draft of the manuscript was written by GD and OK with revisions made by AB. All authors commented on and provided revisions to previous versions of the manuscript. All authors read and approved the final manuscript as submitted.

Corresponding author

Correspondence to Goeto Dantes.

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Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by Children’s Health Care of Atlanta Institutional Review Board (#00001764). Due to the nature of the study and impracticality, individual informed consent was waived. All methods were performed in accordance with the relevant guidelines and regulations. This study was performed in accordance with the Declaration of Helsinki.

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Dantes, G., Keane, O.A., Raikot, S. et al. Necrotizing enterocolitis following spontaneous intestinal perforation in very low birth weight neonates. J Perinatol 45, 642–649 (2025). https://doi.org/10.1038/s41372-024-02155-3

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