On page 16 of this issue, Alysia Agnoni, MS, PA-C, and Christine Lazaros Amendola, MS, PA-C, inform practitioners about necrotizing enterocolitis (NEC) and what they need to do to recognize, diagnose, and treat it. As survival of children born at earlier gestations becomes possible, NEC is one of the most concerning complications of premature birth because it leads to long-term complications and can kill. Compared with other morbidities of early life, NEC is one complication of prematurity with little improvement over the last decade.1 Countries with high use of probiotics, standardized feeding protocols, and human milk feeding show rates lower than in the United States.2,3 Clinicians who do not directly care for neonates in intensive care settings may wonder about the relevance of NEC to their practice. In fact, primary care providers also may be undereducated about this devastating problem, as a review of the recent primary care literature barely mentions NEC.
The good news is that actions taken to prevent NEC can systematically support the health of both the infant and the mother in the long term, especially actions to prevent premature birth and support breastfeeding. Providing infants with early and exclusive access to human milk has been shown to reduce NEC.3,4 Colaizy and colleagues estimate that suboptimal feeding of US infants with formula (that is, less than 90% of infants fed less than 98% of their diet with human milk) is associated with 928 cases of NEC and 121 deaths a year.5 Changing practice to optimize human milk feeding could save $27 million in direct costs of care and up to $1.5 billion related to prematurely lost life every single year.5
Although the exact pathogenesis of NEC is unclear, we know it is multifactorial and that some NICU practices are eliminating the disease from their NICUs.6 This concept of “getting to zero NEC” cannot be done without engaging the entire family and care team. Simple actions backed by evidence that every clinician can do today to prevent NEC include:
NEC is like many conditions for which evidence exists but the consistent implementation of that evidence varies, and NICUs ultimately show different NEC rates. Agnoni and Amendola echo others in the neonatal community when they write that, “Though reports of [NEC] span back at least five decades, its pathogenesis remains an enigma, and the incidence in many NICUs remains the same and has even increased in some.” Yet, perhaps the mystery lies in deciphering how some NICU practices are eliminating or drastically reducing NEC. Perhaps the first step in breaking through scientific inertia lies in bridging the gulf between what we know and what we do.
1. Patel RM, Kandefer S, Walsh MC, et al Causes and timing of death in extremely premature infants from 2000 through 2011. N Engl J Med
2. Jeschke E, Biermann A, Günster C, et al Mortality and major morbidity of very-low-birth-weight infants in Germany 2008-2012: a report based on administrative data. Front Pediatr
3. Alshaikh B, Kostecky L, Blachly N, Yee W. Effect of a quality improvement project to use exclusive mother's own milk on rate of necrotizing enterocolitis in preterm infants. Breastfeed Med
4. Lee HC, Kurtin PS, Wight NE, et al A quality improvement project to increase breast milk use in very low birth weight infants. Pediatrics
5. Colaizy TT, Bartick MC, Jegier BJ, et al Impact of optimized breastfeeding on the costs of necrotizing enterocolitis in extremely low birthweight infants. J Pediatr
6. Talavera MM, Bixler G, Cozzi C, et al Quality improvement initiative to reduce the necrotizing enterocolitis rate in premature infants. Pediatrics
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7. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev
8. Gephart SM, Hanson CK. Preventing necrotizing enterocolitis with standardized feeding protocols: not only possible, but imperative. Adv Neonatal Care
9. Abrahamsson TR, Rautava S, Moore AM, et al The time for a confirmative necrotizing enterocolitis probiotics prevention trial in the extremely low birth weight infant in North America is now! J Pediatr
10. Gephart SM, Martin LB, Kijewski A, Johnson SR. Joseph's story: a case study of late-onset necrotizing enterocolitis from early birth to recovery. J Perinat Neonatal Nurs