Objective To investigate the predictive value of bedside abdominal ultrasound combined with lactate levels in the treatment of neonatal necrotizing enterocolitis (NEC).Methods A retrospective collection was conducted of 94 neonates diagnosed with NEC and meeting the inclusion criteria in Department of Neonatology at Meizhou People's Hospital from February 2019 to December 2024. The neonates were divided into two groups based on their treatment methods: the conservative treatment group (70 cases) and the surgical treatment group (24 cases). Clinical data of the two groups were compared using univariate analysis. Multivariate logistic regression analysis was used to identify risk factors for the treatment methods in NEC patients. The predictive value of related indicators was analyzed using ROC curves. 〖WTHZ〗Results The proportion of perinatal medical history in the surgical treatment group was significantly lower than that in the conservative treatment group (P<0.05). Lactate levels were significantly higher in the surgical treatment group than in the conservative treatment group (P<0.05). Lactate levels, abdominal ultrasound findings, and CRP levels were identified as independent influencing factors for surgical treatment in NEC patients (P<0.05). ROC curve analysis showed that abdominal ultrasound findings, lactate levels, and CRP levels all had certain predictive values, with AUC values of 0.774, 0.842, and 0.737, respectively. The combination of abdominal ultrasound findings and lactate levels had the highest predictive value (AUC=0.896), with a sensitivity of 0.871 and specificity of 0.875. The AUC for the combined use of all three indicators was 0.917. Conclusion Abdominal ultrasound findings, lactate levels, and CRP levels can be used to identify high-risk NEC patients. The combined application of these indicators can achieve a high level of diagnostic sensitivity and specificity, which is helpful for clinicians to identify the timing of surgical intervention