When should a neonate with suspected necrotizing enterocolitis be referred to a specialist for surgical evaluation?

While necrotizing enterocolitis (NEC) is not explicitly named in the provided guidelines for surgical referral, a neonate with suspected NEC should be referred for surgical evaluation if they present with specific "red flag" symptoms indicative of an acute surgical condition ¹,². These symptoms necessitate same-day hospital admission for paediatric surgery assessment ¹.

• Bile-stained (green or yellow-green) vomiting, which may suggest intestinal obstruction, requires paediatric surgery referral ¹,².
• Abdominal distension, tenderness, or a palpable mass, which may suggest intestinal obstruction or another acute surgical condition, requires paediatric surgery referral ¹,².
• Blood in the stool, which may suggest an acute surgical condition, requires specialist referral ².
• Frequent, forceful (projectile) vomiting in infants up to two months of age, suggesting hypertrophic pyloric stenosis, also requires paediatric surgery assessment ¹,².

A "specialist" in this context may refer to a paediatric surgeon, depending on the clinical circumstances ².