Prevention of necrotizing enterocolitis in newborns
- Richard J Schanler, MD
Richard J Schanler, MD
- Hofstra Northwell School of Medicine
Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant. It is a disorder characterized by ischemic necrosis of the intestinal mucosa, which is associated with inflammation, invasion of enteric gas-forming organisms, and dissection of gas into the muscularis and portal venous system . Although early recognition and aggressive treatment of this disorder has improved clinical outcomes, NEC accounts for substantial long-term morbidity in survivors of neonatal intensive care, particularly in preterm very low birth weight (VLBW) infants (BW below 1500 g). As a result, research efforts have focused on finding interventions that will reduce the risk and severity of this disorder.
The prevention of NEC will be reviewed here. The pathology, pathogenesis, clinical features, diagnosis, and management of this disorder are discussed separately. (See "Pathology and pathogenesis of necrotizing enterocolitis in newborns" and "Clinical features and diagnosis of necrotizing enterocolitis in newborns" and "Management of necrotizing enterocolitis in newborns".)
Efforts to minimize the frequency or severity of NEC are directed at reducing exposure to risk factors and finding interventions that will prevent the disorder. The use of human milk versus formula has been shown to reduce the risk of NEC. Other commonly-used preventive measures, most of which have less support, include having a neonatal intensive care unit (NICU) feeding protocol , judicious advancement of enteral feeding (between 15 and 25 mL/kg/day) , the avoidance of hypertonic formulas, hypertonic medications, or contrast agents that may injure the intestinal mucosa, and prompt treatment of polycythemia. These measures are routinely performed in the management of infants cared for in the NICU. (See "Pathology and pathogenesis of necrotizing enterocolitis in newborns", section on 'Medications'.)
HUMAN MILK FEEDING
Human milk compared with formula is the most important strategy associated with a lower risk of NEC (figure 1) [4-8]. This was best illustrated by a meta-analysis of randomized controlled trials which demonstrated that the risk of NEC was increased 2.8 times in infants who were fed formula compared with those who were fed donor human milk (relative risk [RR] 2.77, 95% CI 1.40-5.46) . Thus, in many units, if mothers' own milk is unavailable, pasteurized donor human milk is used, which appears to decrease the risk of NEC . This approach is consistent with the 2012 American Academy of Pediatrics (AAP) breastfeeding policy statement . (See "Pathology and pathogenesis of necrotizing enterocolitis in newborns", section on 'Milk feeding' and "Nutritional composition of human milk and preterm formula for the premature infant" and "Human milk feeding and fortification of human milk for premature infants", section on 'Preterm formula versus donor milk'.)
TIMING AND ADVANCEMENT OF FEEDING
The optimal timing of initiation of minimal enteral (trophic) feeding remains uncertain and its association with NEC is lacking. A systematic review of very low birth weight (VLBW) infants (BW <1500 g) concluded that available data were insufficient to determine whether early feeds (before 96 hours postnatal) were associated with either beneficial or harmful effects . Another systematic review reported advancement of enteral feed volumes at daily increments of 30 to 40 mL/kg compared to lower volumes of 15 to 24 mL/kg did not increase the risk of NEC or death in VLBW infants (BW <1500 g) . In addition, advancing the volumes at slower rates resulted in a delay in establishing full enteral feeds and the risk of invasive infection.
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