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  • Necrotizing enterocolitis (NEC) can occur in full-term newborns with existing medical conditions.

  • Vomiting in a newborn should be considered bilious if it shows a color other than white.

  • A newborn with vomiting, especially bilious emesis, should be evaluated for malrotation with midgut volvulus.

  • Any patient who has suspicion of malrotation with midgut volvulus should undergo an emergent upper GI contrast study with small bowel follow-through.

  • Patients with Hirschsprung’s disease can present with chronic, progressive constipation and failure to thrive.

Neonatal surgical emergencies can occur after discharge from the newborn nursery. They are often life-threatening and require prompt evaluation, stabilization, and emergent referral to a pediatric surgeon. Three such conditions are necrotizing enterocolitis (NEC), malrotation with midgut volvulus, and Hirschsprung’s disease.


NEC is the most common gastrointestinal emergency and the most common cause of intestinal perforation in the newborn period.1 It is usually a disease of preterm infants with low birth weight,2 although nearly 5% to 15% occur in term infants.2–4 Term infants are more likely than their preterm counterparts to have predisposing risk factors2–5 (Table 46-1). A recent trial showed that the administration of probiotics did not impact the risk of developing NEC in preterm infants.6 The vast majority of term infants with NEC have some underlying illness.5 Over 90% of full-term infants with NEC present within the first 4 days of life, and the disease tends to advance more rapidly than in preterm infants.5 Mortality rates of infants with NEC have been reported between 12% and 30%.2,4 The diagnosis of NEC is based upon a three-stage classification system.7,8 Stage I is suspected disease; Stage II is definite disease; and Stage III is advanced disease (Table 46-2).

TABLE 46-1Risk Factors for Necrotizing Enterocolitis in Full-Term Infants
TABLE 46-2Classification System for Necrotizing Enterocolitis

The development of NEC is multifactorial. Enteral intake in the presence of reduced blood flow and bacteria leads to mucosal inflammation and ulceration.9 A compromise in the intestinal mucosal barrier allows bacteria to spread, leading to intestinal perforation, necrosis, and the development of sepsis.10


A high index of suspicion should be maintained, because clinical ...

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