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Necrotizing enterocolitis (NEC) can become severe quickly, making early recognition a priority and understanding the occurrence of abdominal and clinical signs of impending NEC important.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.A 3-site, descriptive correlational case-control design with retrospective data collection was used matching each NEC case to 2 controls (N = 132).NEC cases were exposed to less human milk and fed later. Among them, 61% (n = 27) had at least 1 abdominal 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 unrelated to NEC except for the most severe NEC at 36 hours before diagnosis.Communicating a count of abdominal signs may support earlier recognition and treatment of NEC.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.