Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited. 53 Original Research ❍ Section Editor Donna Dowling, PhD, RN Advances in Neonatal Care • Vol. 17, No. 1 • pp. 53-64 BACKGROUND AND SIGNIFICANCE Necrotizing enterocolitis (NEC) of prematurity is a multifactorial disease, wherein the infant’s immature gastrointestinal system, genetic influences, intestinal microbiota, microvascular tone, and inflammatory response interact to predispose the gut to injury. 1 It is a chief threat to the health of premature infants that can lead to long-term morbidity and developmental delay as well as consuming signifi- cant healthcare resources. Among very low birth- weight (VLBW) infants, the overall incidence of NEC has been reported to vary based on birth weight, gestational age, and sample (see Table 1) with notable variation among centers. 2-8 Conse- quences of NEC can be severe including death, neu- rodevelopment impairment, 9,10 prolonged need for hospitalization and assisted nutrition, and long-term effects from malabsorption disorders like short gut syndrome. 11 When surgery is required, very strong evidence shows that VLBW survivors’ risk for neu- rodevelopment impairment is double that of medical NEC survivors, 9,10 a consistent finding even when rigorous methodology is used and confounders are adjusted. 12 Long-term bowel problems and other functional impairments have also been reported. 13 Clearly, supporting early recognition and prompt treatment to avoid surgical NEC could improve out- comes for infants in the short- and long-term. Variations in NEC Incidence and Severity Medical NEC is managed with nonsurgical approaches (eg, antibiotics, bowel rest, serial radiog- raphy, and gastric decompression). Surgical NEC refers to those who require surgery (either The ConNECtion Between Abdominal Signs and Necrotizing Enterocolitis in Infants 501 to 1500 g Sheila M. Gephart, PhD, RN; Michelle Fleiner , DNP, RNC-NIC, CCNS; Amy Kijewski, FNP-BC, DNP ABSTRACT Background: Necrotizing enterocolitis (NEC) can become severe quickly, making early recognition a priority and under- standing the occurrence of abdominal and clinical signs of impending NEC important. Purpose: The purpose of this study was to examine relationships of abdominal signs up to 36 hours before diagnosis of NEC within subgroups treated medically, surgically, or those who died. Methods: A 3-site, descriptive correlational case-control design with retrospective data collection was used matching each NEC case to 2 controls (N = 132). Results: NEC cases were exposed to less human milk and fed later. Among them, 61% (n = 27) had at least 1 abdomi- nal sign 36 hours before diagnosis, with fewer numbers having 2 (18%; n = 8) or 3 (5%; n = 2). At 36 hours before NEC, abdominal distension, duskiness, higher gastric residual, and greater count of abdominal signs were associated with severe NEC. No medical NEC cases had abdominal signs 36 or 24 hours before diagnosis. Highest severity of NEC was related to more abdominal signs at the times leading up to and at diagnosis of NEC. Gastric residuals were largely unre- lated to NEC except for the most severe NEC at 36 hours before diagnosis. Implications for Practice: Communicating a count of abdominal signs may support earlier recognition and treatment of NEC. Implications for Research: More research is needed to explore timing for clinical worsening of status (eg, surgical and NEC leading to death) and to study effective clinical approaches targeting early recognition to support timely action. Key Words: abdominal assessment, abdominal signs, Bell’s criteria, clinical assessment, feeding intolerance, necrotizing enterocolitis, neonatal intensive care unit, neonate, nursing, very low-birth weight Author Affiliations: The University of Arizona College of Nursing, Tucson, Arizona (Drs Gephart and Kijewski); and Banner Health, Cardon Children’s Medical Center, Mesa, Arizona (Dr Fleiner). Work took place at Banner Health in Arizona and analysis was completed at the University of Arizona. This project was funded by the Lawrence B. Emmons Foundation from the University of Arizona and supported by Banner Health. Dr Gephart acknowledges research support from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program and the Agency for Healthcare Research and Quality (K08HS022908). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or Robert Wood Johnson Foundation. The authors declare no conflicts of interest. Correspondence: Sheila M. Gephart, PhD, RN, Assistant Professor, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 (gepharts@email.arizona.edu). Copyright © 2017 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000345