Virtual elimination of necrotising enterocolitis for 5 years - reasons?

Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.

NEC-zero recommendations from scoping review of evidence to prevent and foster timely recognition of necrotizing enterocolitis

BACKGROUND

Although decades have focused on unraveling its etiology, necrotizing enterocolitis (NEC) remains a chief threat to the health of premature infants. Both modifiable and non-modifiable risk factors contribute to varying rates of disease across neonatal intensive care units (NICUs).

PURPOSE

The purpose of this paper is to present a scoping review with two new meta-analyses, clinical recommendations, and implementation strategies to prevent and foster timely recognition of NEC.

METHODS

Using the Translating Research into Practice (TRIP) framework, we conducted a stakeholder-engaged scoping review to classify strength of evidence and form implementation recommendations using GRADE criteria across subgroup areas: 1) promoting human milk, 2) feeding protocols and transfusion, 3) timely recognition strategies, and 4) medication stewardship. Sub-groups answered 5 key questions, reviewed 11 position statements and 71 research reports. Meta-analyses with random effects were conducted on effects of standardized feeding protocols and donor human milk derived fortifiers on NEC.

RESULTS

Quality of evidence ranged from very low (timely recognition) to moderate (feeding protocols, prioritize human milk, limiting antibiotics and antacids). Prioritizing human milk, feeding protocols and avoiding antacids were strongly recommended. Weak recommendations (i.e. "probably do it") for limiting antibiotics and use of a standard timely recognition approach are presented. Meta-analysis of data from infants weighing <1250 g fed donor human milk based fortifier had reduced odds of NEC compared to those fed cow's milk based fortifier (OR = 0.36, 95% CI 0.13, 1.00; p = 0.05; 4 studies, N = 1164). Use of standardized feeding protocols for infants <1500 g reduced odds of NEC by 67% (OR = 0.33, 95% CI 0.17, 0.65, p = 0.001; 9 studies; N = 4755 infants). Parents recommended that NEC information be shared early in the NICU stay, when feedings were adjusted, or feeding intolerance occurred via print and video materials to supplement verbal instruction.

DISCUSSION

Evidence for NEC prevention is of sufficient quality to implement. Implementation that addresses system-level interventions that engage the whole team, including parents, will yield the best impact to prevent NEC and foster its timely recognition.

Reducing Incidence of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Due to its multifactorial nature, there has been much uncertainty in identifying clear strategies for prevention of NEC. Despite these obstacles, the incidence of NEC has gradually been decreasing over the past 10 years, in part due to quality improvement (QI) initiatives to prevent NEC. Current QI strategies primarily target the various predisposing conditions. This article reviews the evidence on which QI interventions to prevent NEC have been based and provides examples of successful QI interventions.

Standardized feeding regimen for reducing necrotizing enterocolitis in preterm infants: an updated systematic review

OBJECTIVE

A systematic review (2005) of observational studies has reported 87% reduction in the incidence of necrotizing enterocolitis (NEC) after introducing standardized feeding regimen (SFR) in preterm infants. Considering the many new studies in this field since 2005 and the continued health burden of NEC, we aimed to systematically review the incidence of NEC in preterm infants 'before' vs 'after' implementing a SFR.

STUDY DESIGN

PubMed, EMBASE, CINAHL and E-abstracts from the Pediatric Academic Society meetings and other pediatric and neonatal conference proceedings were searched in May 2016. Observational studies reporting incidence of NEC before and after implementing a SFR were included. Relevant data were extracted independently by two reviewers. Meta-analysis was conducted using random effects model (REM) and results rechecked with fixed effects model.

RESULTS

Pooled results from 15 observational studies (N=18 160) using REM showed that SFR significantly reduced the incidence of NEC (risk ratio 0.22; 95% confidence interval 0.13 to 0.36; P<0.00001; I2=74%). The results remained significant after comparing studies in two epochs (1978 to 2003 vs 2004 to 2016).

CONCLUSION

SFR continues to be an important tool in prevention of NEC in preterm infants.

Prevention and early recognition of necrotizing enterocolitis: a tale of 2 tools--eNEC and GutCheckNEC

BACKGROUND AND SIGNIFICANCE

Risk for neonatal necrotizing enterocolitis (NEC) is complex, reflecting its multifactorial pathogenesis.

PURPOSE

To improve risk awareness and facilitate communication among neonatal caregivers, especially nurses, 2 tools were developed.

DESIGN

GutCheck was derived and validated as part of a formal research study over 3 phases, evidence synthesis, expert consensus building, and statistical modeling. The Wetzel/Krisman tool, eNEC, was developed and tested as part of a quality improvement initiative in a single clinical setting using evidence synthesis, review by internal expert clinicians, and implementation and evaluation of its use by direct line neonatal staff. Refinement of both tools is under way to evaluate their effect on clinical decision making, early identification of NEC and surgical NEC.

METHODS AND MAIN OUTCOMES

Clinicians can take an active role to reduce NEC in their units by focusing on modifiable risk factors such as adoption of standardized feeding protocols, preferential feeding of human milk, and antibiotic and histamine blocker stewardship.

RESULTS

Feeding during transfusion remains controversial, but judicious use of transfusions, adoption of transfusion guidelines, and withholding feeding during transfusion are feasible measures with potential benefit to prevent NEC and confer little risk.

Necrotizing enterocolitis risk: state of the science

Necrotizing enterocolitis (NEC) is the most common cause of gastrointestinal-related morbidity and mortality in the neonatal intensive care unit (NICU). Its onset is sudden and the smallest, most premature infants are the most vulnerable. Necrotizing enterocolitis is a costly disease, accounting for nearly 20% of NICU costs annually. Necrotizing enterocolitis survivors requiring surgery often stay in the NICU more than 90 days and are among those most likely to stay more than 6 months. Significant variations exist in the incidence across regions and units. Although the only consistent independent predictors for NEC remain prematurity and formula feeding, others exist that could increase risk when combined. Awareness of NEC risk factors and adopting practices to reduce NEC risk, including human milk feeding, the use of feeding guidelines, and probiotics, have been shown to reduce the incidence of NEC. The purpose of this review is to examine the state of the science on NEC risk factors and make recommendations for practice and research.

Prevention of necrotising enterocolitis: Year 2004 and beyond

The incidence of necrotising enterocolitis (NEC) has not changed significantly despite the dramatic advances in perinatal-neonatal care. The absolute number of survivors of NEC is expected to rise, as prevention of prematurity, the single most important risk factor for the illness, continues to be difficult. Prevention of NEC has thus become an area of research priority. Given the role of inflammatory mediators in its pathogenesis newer immune modulators are being studied as potential agents for prevention/treatment of NEC. Caution, however, is warranted because the failure of sepsis trials in adults has clearly indicated that the concept of down-regulating the inflammatory response is deceptively simple. Clinical trials of any such promising preventative agent(s) need to be designed carefully and must include long-term neurodevelopmental outcomes as almost an entire population of high-risk preterm neonates will be exposed to their adverse effects. As new frontiers continue to be explored, the proven benefits of simple and safe interventions like antenatal glucocorticoid therapy and the preferential use of breast milk for feeding high-risk neonates must not be forgotten. Given that a single effective agent is unlikely in the near future, utilizing a package of "potentially better practices" seems to be the most appropriate strategy to prevent and minimize NEC.

The relationship between feeding and necrotizing enterocolitis in very low birth weight infants

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the NICU, with often devastating consequences. The etiology of NEC is probably multifactorial, with preterm infants at the highest risk. The relationship between feeding and NEC was identified in the 1970s, leading to delayed feeding becoming standard treatment in NICUs. More recent research suggests that early feedings not only are safe, but reduce other morbidities associated with prematurity. Standardized feeding guidelines seem to confer some benefits in decreasing NEC, despite a wide variability in feeding practices within the published guidelines. A standardized approach to the management of feeding problems may be the key. This article briefly reviews the pathogenesis of NEC and examines studies of various feeding practices for their relationship to the development of NEC. It also highlights the potential benefits of breast milk in NEC prevention.

Prevention of necrotizing enterocolitis in preterm infants: a 20-year experience

OBJECTIVE

Diet, indomethacin, and early use of dexamethasone have been implicated as possible causes of necrotizing enterocolitis and intestinal perforation. Because we seldom prescribe indomethacin or early dexamethasone therapy and we follow a special dietary regimen that provides late-onset, slow, continuous drip enteral feeding, we reviewed our 20 years of experience for the incidence of necrotizing enterocolitis and bowel perforation.

METHODS

We reviewed data on all 1239 very low birth weight infants (501-1500 g) admitted to our level III unit over a period of 20 years (1986-2005), for morphologic parameters, necrotizing enterocolitis, bowel perforation, use of the late-onset, slow, continuous drip protocol, and indomethacin therapy. Outcome data were also compared with Vermont Oxford Network data for the last 4 years.

RESULTS

In 20 years, 1158 infants received the late-onset, slow, continuous drip feeding protocol (group I), whereas 81 infants had either a change in dietary regimen, use of indomethacin, or early use of dexamethasone (group II). The rate of necrotizing enterocolitis in group I of 0.4% was significantly lower than that in group II of 6%. Group I, in comparison with the Vermont Oxford Network, had significantly lower rates of necrotizing enterocolitis (0.4% vs 5.9%), surgical necrotizing enterocolitis (0.4% vs 3.1%), and bowel perforation (0.35% vs 2.2%).

CONCLUSIONS

Our 20-year experience with 1239 very low birth weight infants suggests strongly that the late-onset, slow, continuous drip feeding protocol and avoidance of indomethacin and early dexamethasone treatment contribute to the prevention of necrotizing enterocolitis.

Strategies for prevention of feed intolerance in preterm neonates: a systematic review

Postnatal growth restriction and failure to thrive have been recently identified as a major issue in preterm, especially extremely-low-birth-weight neonates. An increased length of time to reach full enteral feedings is also significantly associated with a poorer mental outcome in preterm neonates at 24 months corrected age. Optimization of enteral nutrition without increasing the risk of necrotizing enterocolitis (NEC) has thus become a priority in preterm neonates. A range of feeding strategies currently exists for preventing/minimizing feed intolerance in preterm neonates reflecting the dilemma surrounding the definition and significance of signs of feed intolerance due to ileus of prematurity and the fear of NEC. The results of a systematic review of current strategies for preventing/minimizing feed intolerance in preterm neonates are discussed. The need for clinical research in the area of signs of feed intolerance is emphasized to develop a scientific basis to feeding strategies. Only large pragmatic trials based on such strategies will reveal whether the benefits (improved growth and long term neurodevelopmental outcomes) of aggressive enteral nutrition can outweigh the risks of a potentially devastating illness like NEC, and of prolonged parenteral nutrition in preterm neonates.

Does carboxymethylcellulose have a role in reducing time to full enteral feeds in preterm neonates?

The efficacy of prophylactic carboxymethylcellulose (CMC) in reducing the time to reach full enteral feeds (FEFs) in neonates <32 weeks' gestation was studied in a clinical trial. When ready for feeds, enrolled neonates were allocated to either CMC (dose: CMC content of 12 mg oral erythromycin ethyl succinate syrup, 6 hourly) or placebo till either maximum 10 days treatment or FEF (150 ml/kg/day) was reached. A standardised regimen guided enteral feeding. Demographic characteristics of enrolled neonates (CMC, placebo: n = 35) were comparable. Median (interquartile range) gestational age and birth weight were 29 (28, 30) vs. 29 (27, 31) weeks and 1090 (905, 1390) vs. 1236 g (928, 1565) for the CMC and placebo groups, respectively. Median (interquartile range) time to reach FEF was 5 (4, 6) vs. 5 (3, 8) days for CMC and placebo group, respectively (p = 0.5). No CMC-related adverse effects occurred. Prophylactic CMC did not have a significant role in reducing time to reach FEF.

Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies

BACKGROUND

A significant and prolonged decline in the incidence of necrotising enterocolitis (NEC), nearing virtual elimination in some centres, has been observed consistently since implementation of a standardised feeding regimen.

AIM

To systematically review the observational studies reporting incidence of NEC in preterm, low birth weight (LBW) neonates "before" and "after" implementation of a standardised feeding regimen.

METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2002), Medline, Embase, Cinahl, and proceedings of the Pediatric Academic Societies (published in Pediatric Research from 1980) were searched in July and again in October 2003. The reference lists of identified observational studies, and personal files, were searched. No language restriction was applied. Key words were: standardised, enteral, feeding, neonates, necrotising enterocolitis. Authors were contacted for clarification of data.

RESULTS

Six eligible studies (1978-2003) were identified. A significant heterogeneity was noted between the studies indicating the variations in the population characteristics and feeding practices over a period of 25 years. Meta-analysis of the six studies using a random effects model revealed a pooled risk ratio of 0.13 (95% confidence interval 0.03 to 0.50)-that is, introduction of a standardised feeding regimen reduced the incidence of NEC by 87%.

CONCLUSION

Standardised feeding regimens may provide the single most important global tool to prevent/minimise NEC in preterm neonates. Randomised controlled trials are needed.