Pneumatosis intestinalis: Does it always indicate necrotizing enterocolitis?

Pneumatosis intestinalis (PI) is a rare radiological finding that may be associated with various diseases. In the neonatal period, it is considered pathognomonic for necrotizing enterocolitis (NEC). Cow's milk protein allergy (CMA) is the main cause of allergy especially in term infants appearing following breastfeeding or consumption of milk-based formulas.

We report three neonates presenting with PI and diagnosed with CMA and/or NEC. Case 1 was a 44-day-old preterm infant admitted to the hospital for nutritional deficiency and jaundice, who later developed PI and a NEC-like appearance (NEC-LA). Case 2 was born at 28 weeks' gestation and developed PI and NEC-LA five times. Case 3 was a 24-day-old term neonate who was admitted to the hospital due to acute gastroenteritis and developed PI and NEC-LA. Only case three required a surgical intervention. After feeding the infants an amino acid-based formula, clinical manifestations improved quickly, and the disease did not relapse. In our opinion, CMA was the correct diagnosis for cases 1 and 3. However, case 2 developed two NEC episodes and three NEC-LA episodes, which were thought to be related to CMA.

In addition to NEC, CMA should be considered in every PI, and recurrent NEC feeding should begin in accordance with a CMA management protocol.