Current Management of Pneumatosis Intestinalis in Children: A Review

IMPORTANCE: Pneumatosis intestinalis (PI), defined by the presence of gas within the bowel wall, ranges in severity from a benign, incidental finding to a life-threatening condition. The true incidence in children is unclear, and standardized treatment protocols are lacking, resulting in variable management and potential for both over- and undertreatment. This review summarizes current knowledge on pediatric PI, including pathophysiology, clinical presentation, diagnostics, treatment strategies, and risk stratification. OBSERVATIONS: Development of PI is multifactorial, involving mechanical, bacterial, and biochemical mechanisms. Risk factors include necrotizing enterocolitis, immunosuppressive therapy, gastrointestinal dysmotility, developmental delay, and congenital anomalies. Clinical presentation ranges from asymptomatic cases discovered incidentally to severe disease with clinical symptoms and sepsis. PI can be identified on plain radiographs, ultrasonography, and cross-sectional imaging. Abnormal complete blood counts, elevated inflammatory markers, and metabolic acidosis are markers of severity. Treatment depends on the severity and underlying cause, with conservative management indicated for stable patients and surgical intervention required for those with signs of intestinal necrosis or perforation. Risk-stratification models are necessary to guide individualized management, minimizing prolonged bowel rest and antibiotic use while ensuring timely interventions for high-risk patients. CONCLUSIONS: Managing pediatric PI requires an understanding of its diverse presentations, diagnostic methods, and treatment options. Evidence-based risk-stratification protocols could minimize practice variability and optimize care, differentiating patients who are appropriate for conservative management from those who require escalation of care. This review serves as a guide for clinicians navigating the diagnostic and therapeutic challenges associated with PI in children.