›Gentamicin
›Gentamicin 4 to 5 mg/kg/dose intravenously
›Interval every 24 hours in term infants, every 36 hours at 30 to 34 weeks postmenstrual age, and every 48 hours below 30 weeks
›Monitor trough concentration and renal function, and extend the interval or switch agent in acute kidney injury
›Dosing is capped by trough and peak targets rather than a fixed milligram ceiling
›Metronidazole
›Metronidazole loading dose 15 mg/kg intravenously, then 7.5 mg/kg/dose
›Interval every 12 hours in term infants, every 12 to 24 hours in preterm infants, and up to every 48 hours below 28 weeks postmenstrual age in the first week
›This is the default anaerobic agent added for pneumatosis or perforation
›Alternative and adjunct agents
›Piperacillin-tazobactam 80 to 100 mg/kg/dose of the piperacillin component intravenously every 6 to 8 hours by postmenstrual age, a single agent covering gram-negative, gram-positive, and anaerobic organisms
›Cefotaxime 50 mg/kg/dose intravenously every 8 to 12 hours by age, a third-generation cephalosporin paired with ampicillin and metronidazole
›Ceftriaxone 50 mg/kg/dose is contraindicated in the neonate because it displaces bilirubin and precipitates with calcium; use cefotaxime instead
›Vancomycin 15 mg/kg/dose intravenously every 12 to 24 hours by postmenstrual age, dosed to a trough or area-under-curve target, reserved for suspected methicillin-resistant or coagulase-negative staphylococcal line sepsis or severe stage III disease
›Clindamycin 5 to 9 mg/kg/dose intravenously every 6 to 8 hours as an alternative anaerobic agent, less favoured because it selects for gram-negative resistance
›Fluconazole 12 mg/kg/dose intravenously as a loading dose then 6 to 12 mg/kg/day for candidal risk with no improvement at 48 to 72 hours, a central line, or prolonged prior antibiotics
›Duration
›7 to 14 days for Bell stage II and III, mirroring bowel rest, with the C-reactive protein trend and clinical course guiding the endpoint
›48 to 72 hours may be sufficient for stage I once the picture settles and cultures are negative
Haemodynamic and respiratory support
›Vasoactive infusions for fluid-refractory shock
›Epinephrine 0.05 to 0.3 mcg/kg/min intravenously, first line for low cardiac output with poor contractility
›Titrate by 0.05 mcg/kg/min every 5 to 10 minutes to perfusion and blood pressure targets
›Step down to 0.02 to 0.03 mcg/kg/min increments as targets are approached to avoid tachyarrhythmia and excess afterload
›Deliver through a central or umbilical venous catheter, because peripheral extravasation causes skin necrosis
›Verify against current pediatric guideline before use
›Norepinephrine 0.05 to 0.5 mcg/kg/min intravenously for warm vasodilated shock
›Titrate to mean arterial pressure while watching for splanchnic and renal hypoperfusion
›Verify against current pediatric guideline before use
›Dopamine 5 to 20 mcg/kg/min intravenously remains an option, but higher doses worsen mesenteric and pulmonary vascular tone
›Dobutamine 5 to 20 mcg/kg/min intravenously for predominant myocardial dysfunction
›Hydrocortisone 1 mg/kg intravenously every 8 hours for catecholamine-resistant shock or suspected relative adrenal insufficiency
›Choosing the agent against the physiology
›The goal is to restore perfusion pressure without extending bowel ischaemia, so titrate to the lowest effective dose and reassess abdominal findings
›Every vasoconstrictor can convert marginal bowel to necrotic bowel, which is the argument for adequate volume and inotropy before a pure vasopressor
›Respiratory support
›Intubate for apnoea, respiratory failure, or a distended abdomen splinting the diaphragm, decompressing the stomach with the orogastric tube first
›Avoid prolonged bag-mask ventilation, which insufflates the stomach and worsens distension and perforation risk
›Set an oxygen saturation target of 90 to 95% for the preterm infant receiving oxygen
›Accept a lower preductal target around 75 to 85% in cyanotic or single-ventricle congenital heart disease to balance pulmonary and systemic flow
›Target preductal 91 to 95% and avoid hypoxaemic swings in pulmonary hypertension or persistent pulmonary hypertension of the newborn
›Accept 90 to 95% without hyperoxia in established chronic lung disease of prematurity
›Lung-protective tidal volumes and cautious positive end-expiratory pressure, because high intrathoracic pressure reduces venous return in the hypovolaemic septic infant
Correction of coagulopathy and metabolic derangement
›Blood component therapy
›Packed red cells 10 to 15 mL/kg intravenously for a haemoglobin below the unit threshold or active bleeding, transfused over 3 to 4 hours where volume tolerance allows
›Platelets 10 to 15 mL/kg for a count below 50 ×10⁹/l with bleeding or below 20 to 30 ×10⁹/l without, recognising that a rapid platelet fall itself signals necrotic bowel
›Fresh frozen plasma 10 to 15 mL/kg for disseminated intravascular coagulation with bleeding and prolonged clotting times
›Cryoprecipitate 5 to 10 mL/kg for fibrinogen below 1.0 g/l
›Vitamin K 1 mg intramuscularly if birth prophylaxis was missed or declined and coagulopathy is present
›Metabolic targets
›Treat metabolic acidosis by restoring perfusion rather than by routine buffering, reserving sodium bicarbonate 1 to 2 mmol/kg intravenously, diluted and given slowly, for severe acidaemia with haemodynamic compromise
›Keep glucose in a physiologic range with a continuous dextrose infusion, avoiding both hypoglycaemia below 2.6 mmol/l and sustained hyperglycaemia
›Anticipate hypokalaemia from nasogastric losses and any bicarbonate therapy, and hyperkalaemia from necrosis and acute kidney injury
›ECG and rhythm surveillance during electrolyte shifts
›Obtain an ECG or rhythm strip for peaked T waves, a widening QRS, or bradyarrhythmia with hyperkalaemia from bowel necrosis, haemolysis, or renal failure
›Watch for a prolonged QT interval from hypocalcaemia after citrated blood products, and for flattened T waves and U waves with hypokalaemia
›Treat the rhythm-threatening electrolyte abnormality before it produces arrest
Analgesia, sedation, and procedural drugs
›Analgesia
›Fentanyl 1 to 2 mcg/kg/dose intravenously by slow push over 2 to 3 minutes for procedural or ongoing pain, or an infusion 0.5 to 2 mcg/kg/h
›Rapid administration causes chest wall rigidity, so give slowly and have a neuromuscular blocker available
›Verify against current pediatric guideline before use
›Morphine 0.05 to 0.1 mg/kg/dose intravenously is an alternative but deepens ileus and drops vascular tone in the volume-depleted infant
›Acetaminophen 10 to 15 mg/kg/dose intravenously or rectally every 6 hours for fever or mild pain, avoiding the enteral route during bowel rest
›Maximum 60 mg/kg/day in term infants, 40 mg/kg/day at 32 to 37 weeks, and 30 to 40 mg/kg/day below 32 weeks with an interval of every 8 to 12 hours
›Non-steroidal anti-inflammatory drugs are contraindicated for analgesia here because they cause mesenteric vasoconstriction
›Intubation drugs
›Atropine 20 mcg/kg intravenously to blunt vagal bradycardia
›Verify against current pediatric guideline before use
›Fentanyl 1 to 4 mcg/kg intravenously by slow push as the induction analgesic
›Verify against current pediatric guideline before use
›Rocuronium 1 mg/kg intravenously, or vecuronium 0.1 mg/kg intravenously, for paralysis
›Verify against current pediatric guideline before use
›Avoid a single-agent ketamine 1 to 2 mg/kg intravenously or a propofol bolus in the shocked infant; if midazolam is used for maintenance, 0.05 to 0.15 mg/kg with no bolus during hypotension
›Verify against current pediatric guideline before use
›Sedation strategy
›Use the lowest effective sedation, because accumulation prolongs ventilation and cumulative opioid and benzodiazepine exposure is linked to adverse neurodevelopment
›Volume-resuscitate before sedating, since every sedative unmasks hypovolaemia
Surgical and interventional management
›Preoperative optimisation
›Correct coagulopathy, transfuse to a safe haemoglobin, and stabilise ventilation and perfusion before transfer to theatre where time allows
›Continue antibiotics and decompression through the operative period
›Consent discussion covering resection, stoma, short bowel risk, and mortality
›Procedure choice
›Laparotomy with resection of frankly necrotic segments and stoma, preserving bowel length, sometimes staged with a planned second look
›Primary peritoneal drainage at the bedside under local anaesthesia for the unstable extremely low birth weight infant, as temporising control or occasionally definitive
›Randomised comparisons have not shown a clear survival or neurodevelopmental advantage of either first approach
›Postoperative course
›Prolonged parenteral nutrition through a central line with monitoring for intestinal failure-associated liver disease
›Contrast study of the distal limb before stoma closure to exclude a stricture
›Surveillance for short bowel syndrome after extensive resection
Monitoring and response to therapy
›Monitoring cadence
›Abdominal examination and girth every 1 to 2 hours during the acute phase, by the same examiner where possible
›Abdominal radiograph every 6 hours while disease is evolving, and immediately with any deterioration
›Blood gas, lactate, and glucose every 2 to 4 hours, and more often during vasoactive titration
›Complete blood count and C-reactive protein every 12 to 24 hours, with platelets more often if falling
›Continuous heart rate, respiratory rate, oxygen saturation, and blood pressure, with blood pressure every 5 to 15 minutes during infusion titration and hourly urine output
›Signs of an adequate response
›Stable or improving abdominal examination, resolving acidosis and lactate, a rising platelet count, and decreasing ventilatory and vasoactive support over 24 to 72 hours
›Therapy is not working
›Persistent or worsening acidosis, thrombocytopenia, pressor requirement, or distension beyond 24 to 48 hours triggers a structured reassessment
›Repeat imaging for interval perforation or a fixed necrotic loop
›Reconsider source control and escalate to laparotomy
›Broaden antibacterial cover and add an antifungal for a resistant or fungal organism
›Look for abdominal compartment physiology with oliguria and high ventilation pressures
›Revisit the diagnosis for malrotation with volvulus, spontaneous intestinal perforation, or Hirschsprung enterocolitis
›Confirm resuscitation adequacy, central access, and that antibiotic doses and intervals are correct for age
Interventions to avoid or modify
›Enteral feeding
›The highest-risk action is resuming or advancing enteral feeds during active disease, which feeds luminal bacteria and drives recurrent or extended necrosis
›Reintroduce feeds only after the stage-appropriate bowel rest, a benign abdomen, and normal imaging, advancing slowly at about 15 to 20 mL/kg/day
›Intubation and ventilation
›Decompress the stomach before bag-mask ventilation and keep the orogastric tube venting to prevent diaphragmatic splinting and perforation
›Limit positive end-expiratory pressure that reduces venous return in the hypovolaemic infant
›Sedation and analgesia
›Opioids worsen the existing ileus and cause hypotension in the volume-depleted infant, so volume-resuscitate first and use the lowest effective dose
›Indomethacin 0.1 to 0.2 mg/kg/dose intravenously and ibuprofen 10 mg/kg then 5 mg/kg at 24 and 48 hours for patent ductus arteriosus cause mesenteric vasoconstriction and are held during active necrotizing enterocolitis
›Fluid loading
›Necessary for large third-space losses, but over-resuscitation produces bowel wall oedema, pulmonary oedema, and ductal reopening and is associated with worse outcomes
›Titrate to urine output and lactate, reassessing the liver edge and lungs after each bolus
›Oxygen
›Avoid hyperoxia; target 90 to 95% saturation in the preterm infant and use the disease-specific targets in cyanotic heart disease, pulmonary hypertension, and chronic lung disease
›Vasopressors
›Every vasoconstrictor can extend bowel ischaemia, so optimise volume and inotropy first and deliver pressors centrally to avoid extravasation necrosis
›Mechanical circulatory support
›Intra-aortic balloon pump has no role in the neonate
›Extracorporeal membrane oxygenation is relatively contraindicated with active necrotizing enterocolitis because systemic anticoagulation worsens intestinal and intracranial haemorrhage
›Anticoagulation and fibrinolysis
›Do not give therapeutic heparin for the disseminated intravascular coagulation of necrotizing enterocolitis; manage it with factor and platelet replacement
›Fibrinolytic therapy is contraindicated because of bowel and intracranial bleeding risk
›Acid suppression and probiotics
›Histamine-2 receptor antagonists and proton pump inhibitors raise necrotizing enterocolitis risk and are stopped unless there is a compelling separate indication
›Probiotics are a prevention strategy only and are not started during active disease because of the risk of probiotic bacteraemia or fungaemia
›Enteral medications and catheters
›Avoid hyperosmolar oral medications and contrast down the orogastric tube during bowel rest
›Reconsider the need for an umbilical arterial catheter, which is associated with necrotizing enterocolitis, weighing removal against access needs