Human and Bovine Colostrum for Prevention of Necrotizing Enterocolitis: A Meta-analysis

Lactoferrin: Properties and Potential Uses in the Food Industry

Lactoferrin (LF) is an 80 kDa glycoprotein that contains approximately 700 amino acids and is a member of the transferrin family. The essential properties of LF, including antimicrobial, antiviral, anticancer, anti-inflammatory, antioxidant, and probiotic effects, have been studied for decades. The iron chelation activity of LF is significantly associated with its antimicrobial, anti-inflammatory, and antioxidant properties. Owing to its probiotic and prebiotic activity, LF also facilitates the growth of beneficial microorganisms and iron-defense immediate-effect properties on pathogens. Additionally, the ability to regulate cell signaling pathways and immune responses makes LF a prominent modulatory protein. These diverse characteristics of LF have gained interest in its therapeutic potential. Studies have suggested that LF could serve as an alternative source to antibiotics in severe infections and illnesses. LF has also gained interest in the food industry for its potential as an additive to fortify products such as yogurt, infant formula, and meat derivatives while also improving the shelf life of foods and providing antimicrobial and antioxidant activity. Prior to using LF in the food industry, the safety and toxicity of food processing are necessary to be investigated. These safety investigations are crucial for addressing potential harm or side effects and ensuring a healthy lifestyle. This review discusses the attributes and safety of LF, particularly its exploitation in the food industry.

Bovine Colostrum in Pediatric Nutrition and Health

Bovine colostrum (BC), the first milk secreted by mammals after birth, is a trending alternative source for supplementing infants and children, offering benefits for gut and immune health. Its rich components, such as proteins, immunoglobulins, lactoferrin, and glycans, are used to fortify diets and support development. Preterm development is crucial, especially in the maturation of essential systems, and from 2010 to 2020, approximately 15% of all premature births occurred at less than 32 weeks of gestation worldwide. This review explores the composition, benefits, and effects of BC on general infants and children, along with preterm infants who require special care, and highlights its role in growth and development. BC is also associated with specific pediatric diseases, including necrotizing enterocolitis (NEC), infectious diarrhea, inflammatory bowel disease (IBD), short-bowel syndrome (SBS), neonatal sepsis, gastrointestinal and respiratory infections, and some minor conditions. This review also discusses the clinical trials regarding these specific conditions which are occasionally encountered in preterm infants. The anti-inflammatory, antimicrobial, immunomodulatory, and antiviral properties of BC are discussed, emphasizing its mechanisms of action. Clinical trials, particularly in humans, provide evidence supporting the inclusion of BC in formulas and diets, although precise standards for age, feeding time, and amounts are needed to ensure safety and efficacy. However, potential adverse effects, such as allergic reactions to caseins and immunoglobulin E, must be considered. More comprehensive clinical trials are necessary to expand the evidence on BC in infant feeding, and glycans, important components of BC, should be further studied for their synergistic effects on pediatric diseases. Ultimately, BC shows promise for pediatric health and should be incorporated into nutritional supplements with caution.

Nutritional and health effects of bovine colostrum in neonates

High concentrations of immunoglobulins, bioactive peptides, and growth factors are found in bovine colostrum (BC), the milk produced by cows in the first few days after parturition. Various biological functions make it increasingly used to provide nutritional support and immune protection to the offspring of many species, including humans. These biological functions include cell growth stimulation, anti-infection, and immunomodulation. The primary components and biological functions of colostrum were reviewed in the literature, and the authors also looked at its latent effects on the growth and development of neonates as well as on conditions such as infections, necrotizing enterocolitis, short bowel syndrome, and feeding intolerance. The importance of BC in neonatal nutrition, immune support, growth and development, and gut health has been demonstrated in a number of experimental and animal studies. BC has also been shown to be safe at low doses without adverse effects in newborns. BC supplementation has been shown to be efficient in preventing several disorders, including rotavirus diarrhea, necrotizing enterocolitis, and sepsis in animal models of prematurity and some newborn studies. Therefore, BC supplementation should be considered in cases where maternal milk is insufficient or donor milk is unavailable. The optimal age, timing, dosage, and form of BC administration still require further investigation.

Exclusive Human Milk Diets and the Reduction of Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is common in preterm infants, especially infants less than 32 weeks gestation. Mortality from NEC is 7% and occurs in 1 out of 1000 preterm infants. Studies have shown the efficacy of an exclusive milk from mother diet in decreasing rates of NEC and associated mortality.

PURPOSE

To evaluate the effectiveness of an existing exclusive human milk diet (EHMD) protocol on the incidence of NEC in extremely premature infants. EHMD, for the purposes of this project is defined as breast milk of mother, with or without human milk-based fortifier.

METHODS

A single-center retrospective quasi-experimental study. The sample included 201 infants born less than 32 weeks gestation, weighing less than 1250 grams, small for gestational age (SGA) and with low Apgar scores. Outcomes measured included incidences of NEC, mortality, and co-morbidities in infants pre- and postinitiation of an EHMD protocol.

RESULTS

Just 4.8% of the EHMD group had a NEC diagnosis compared to 10.5% of the bovine-based (BOV) group. There was a 1% mortality rate of the EHMD group as compared to 6% in the BOV group. The EHMD group had a statistically significant greater weight gain during hospitalization as compared to infants fed BOV ( P = < .05).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal intensive care units should consider EHMDs for use in this infant population. Future research is needed to support dissemination of the use of EHMD as standard of practice.

Improved physical disability and nutritional status by bovine colostrum supplementation in adults with traumatic peri-trochanteric femoral fracture: A randomized, controlled, clinical trial

OBJECTIVES

Patients with femur fracture after surgery are at risk of malnutrition, weight loss, disability, and mobility complications. In the present study the role of colostrum supplementation on physical disability, and some nutritional variables after surgery has been investigated.

RESEARCH METHODS & PROCEDURES

Patients were randomly assigned to two groups. The intervention group received 45 g colostrum and the control group received 15 g whey protein daily for 21 days (each containing 12 g of protein). The trend comparison during 30 days of variables including weight, appetite, serum albumin level, hemoglobin and lymphocytes between the two groups was modeled with the generalized estimation equation. Moreover, the trend comparison during 90 days of Oswestry Disability Index (ODI) between the two groups was calculated.

RESULTS

The basic characteristics were the same between the two groups (colostrum, n = 46; control, n = 48). Protein intake was the same in both groups during the study period. There was a significant difference in weight gain (ß = 0.32, 95 % CI: 0.09-0.54; P = 0.005) within 30 days after operation between the colostrum and control groups in favor of the increase in the colostrum group. Compared to the control group, patients in the colostrum group had a 0.31 score more appetite (P < 0.001), 0.17 g/dL higher serum albumin level (P = 0.001), 0.5 mg/dL higher hemoglobin level and 440 more blood lymphocytes (P < 0.001) during the 30 days of intervention. Regarding physical function disability, patients in the colostrum group had about 4 ODI scores lower than the control group during the study period.

CONCLUSION

Colostrum supplement can increase appetite, hemoglobin, serum albumin level and the number of blood lymphocytes more than the control group. It can also accelerate weight gain and physical performance after surgery.

Role of the microbiome in pathophysiology of necrotising enterocolitis in preterm neonates

Although necrotising enterocolitis (NEC) is a serious, life-threatening disease, improved neonatal care is increasing the number of survivors with NEC among extremely preterm neonates. Therapy is nevertheless mostly symptomatic and the mortality rate remains high, especially among neonates requiring surgery. Therefore, it is important to focus on preventing the disease and modifiable risk factors. NEC's pathophysiology is multifaceted, with key factors being immaturity of the immune and barrier protective mechanisms of the premature gut and exaggerated proinflammatory reaction to insults like gut hypoxia, enteral nutrition or microbial dysbiosis. The role of the intestinal microbiome in the pathophysiology of NEC has been a subject of research for many years, but to date no specific pathogen or type of dysbiosis has been connected with NEC development. This review assesses current knowledge as to the role of the intestinal microbiota in the pathophysiology of NEC and the possibilities for positively influencing it.

Effect of Bovine Colostrum Dietary Supplementation on Rabbit Meat Quality

Bovine colostrum (BC) is rich in nutrients, antimicrobial, and antioxidant factors; for these reasons, it has been used as supplement in animal nutrition. However, its possible effects on meat quality have not been studied yet. Thirty-nine New Zealand White rabbits (n = 13/group) were assigned to three groups and fed until slaughter with a commercial standard diet, control group (C), and C supplemented with 2.5% and 5% (w/w) of BC (BC-2.5 and BC-5 groups, respectively). After slaughtering, the effect of dietary supplementation on microbiological and chemical characteristics of the rabbit loins was evaluated at 48 h postmortem (D0) and after 3 (D3) and 8 (D8) days of refrigerated storage. Results showed no difference in the microbiological parameters. In the supplemented groups, TBARS and TVBN values were lower and higher than in the C group, respectively (p < 0.01), and their fatty-acid profile was increased in SFA and decreased in MUFA (p < 0.05). In conclusion, research must continue to examine in depth the possible effects of BC byproduct reuse in animal nutrition on meat quality (e.g., antioxidant power, and physical and sensory characteristics).

Insights into the Research Trends on Bovine Colostrum: Beneficial Health Perspectives with Special Reference to Manufacturing of Functional Foods and Feed Supplements

Bovine colostrum (BC) is the initial mammary secretion after parturition, which is nature's bountiful source consisting of nutritional and bioactive components present in a highly concentrated low-volume format. All mammalian newborns require colostrum to enhance physiological processes such as lifelong immunity, gastrointestinal development, and resistance to microbial infections. The genetic, environmental, and processing methods can all have an impact on the biochemical contents of BC and its supplements. BC and its derivatives have been intensively researched for their potential use in functional foods, medicines, and animal feed. Evidence from clinical studies suggests that BC products are well-tolerated, nontoxic, and safe for human ingestion. Functional foods, feed, and pharmaceutical formulations based on bovine colostrum are playing noteworthy roles in the development of innovative products for promoting health and the prevention of chronic illnesses. This systematic review sheds light on recent research on (a) the effects of processing techniques on BC components, (b) emerging techniques used in the isolation and identification of novel components, (c) BC-based functional foods for human consumption and animal feed supplements, and (d) the role of BC in current drug delivery, as well as future recommendations.

Predictive factors for the surgical treatment of necrotizing enterocolitis in preterm infants: a single-center retrospective study

Background

Necrotizing enterocolitis (NEC) is a gastrointestinal disease that tends to occur in premature infants. Some features may be associated with an increased probability that preterm infants with NEC will require surgical treatment. This study aimed to identify the factors that increased the probability of surgical treatment in infants with NEC.

Methods

We retrospectively analyzed the data of premature infants with NEC who were hospitalized at The Affiliated Hospital of Qingdao University from April 2011 to April 2021. According to the treatments received, these patients were divided into medical NEC group and surgical NEC group. The perinatal characteristics, clinical manifestations, and laboratory values before the onset of NEC were subjected to univariate and multivariate analyses.

Results

A total of 623 preterm infants with NEC (> Bell’s stage I) were included in this study, including 350 (56%) who received surgical treatment and 273 (44%) who received conservative medical treatment. Multivariate analysis showed that lower gestational age (P = 0.001, odds ratio (OR) (95% CI) = 0.91[0.86–0.96]), early occurrence of NEC (P = 0.003, OR (95% CI) = 0.86 [0.77–0.95]), hemodynamically significant patent ductus arteriosus (P = 0.003, OR (95% CI) = 7.50 [2.03–28.47]), and low serum bicarbonate (P = 0.043, OR (95% CI) = 0.863 [0.749–0.995]) were associated with an increased probability of surgical treatment in preterm infants with NEC.

Conclusions

Our findings were applied to identify potential predictors for surgical treatment in preterm infants with NEC, which may facilitate early decisive management.

Bioactive compounds, nutritional profile and health benefits of colostrum: a review

Bovine colostrum is defined as first milk by milching animals responsible for providing the innate immunity to the neonatal and possess many immunoglobulins for preventing the calf from diseases. Colostrum consist of many bioactive compounds like proteins, enzymes, growth factors, immunoglobulins and nucleotides that provides several benefits to human health. Numerous clinical and pre-clinical studies have demonstrated the therapeutic benefits of the bovine colostrum. This review focusses on bioactive compounds, their health benefits, potential of colostrum for developing several health foods and prevention of respiratory and gastrointestinal tract disorders. Processing can also be done to extend shelf-life and extraction of bioactive constituents either as encapsulated or as extracts. The products derived from bovine colostrum are high-end supplements possessing high nutraceutical value.

Gut priming with bovine colostrum and T regulatory cells in preterm neonates: a randomized controlled trial

BACKGROUND

Necrotizing enterocolitis (NEC) and neonatal sepsis are still considered major problems, especially in formula-fed preterm neonates. This study aimed to investigate the effect of bovine colostrum on T regulatory cells, NEC, and late-onset sepsis in preterm neonates ≤34 weeks.

METHODS

This prospective double-blind randomized controlled trial was conducted on 80 preterm infants who were randomly assigned to either the bovine colostrum group (n = 32) or control group (n = 48). T lymphocytes and their subsets, necrotizing enterocolitis, late-onset sepsis (LOS) and its severity, feeding tolerance, growth, length of hospital stay, and mortality were documented.

RESULTS

The bovine colostrum group showed higher follow-up levels of CD4+CD25+ FOXP3+ T lymphocyte % (FOXP3 Tregs). FOXP3 Tregs and its difference in change levels between baseline and follow-up were considered as the most related factors to the bovine colostrum. Bovine colostrum group showed positive trends for reduction of sepsis severity and mortality with no significant difference in the incidence of NEC, LOS, and length of hospital stay.

CONCLUSIONS

Preterm neonates who received bovine colostrum showed a higher FOXP3 Treg level.

IMPACT

Bovine colostrum has no significant effect on the incidence of necrotizing enterocolitis. FOXP3 T regulatory cells and their increased level between baseline and follow-up is considered as the most influencing factors related to the bovine colostrum. Positive trends were noted for reduction of sepsis severity and concomitant mortality, but the study lacked the power to assess these outcomes.

Breast milk nutrients driving intestinal epithelial layer maturation via Wnt and Notch signaling: Implications for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is an often lethal, inflammatory disease of the preterm intestine. The underdeveloped immune system plays an important role; however, the initial trigger for NEC development is likely a damaged intestinal epithelial layer. We hypothesize that due to incomplete maturation of different epithelial cell lineages, nutrients and bacteria are able to damage the epithelial cells and cause the (immature) inflammatory response, food intolerance and malabsorption seen in NEC. Intestinal organoid research has shown that maturation of intestinal epithelial cell lineages is orchestrated by two key signaling pathways: Wnt and Notch. In NEC, these pathways are dysregulated by hyperactivation of Toll-like-receptor-4. Breastfeeding decreases the risk of developing NEC compared to formula milk. Here, we review the intricate link between breast milk components, Wnt and Notch signaling and intestinal epithelial maturation. We argue that (nutritional) interventions regulating these pathways may decrease the risk of NEC development in preterm infants.

Potential Benefits of Bovine Colostrum in Pediatric Nutrition and Health

Bovine colostrum (BC), the first milk produced from cows after parturition, is increasingly used as a nutritional supplement to promote gut function and health in other species, including humans. The high levels of whey and casein proteins, immunoglobulins (Igs), and other milk bioactives in BC are adapted to meet the needs of newborn calves. However, BC supplementation may improve health outcomes across other species, especially when immune and gut functions are immature in early life. We provide a review of BC composition and its effects in infants and children in health and selected diseases (diarrhea, infection, growth-failure, preterm birth, necrotizing enterocolitis (NEC), short-bowel syndrome, and mucositis). Human trials and animal studies (mainly in piglets) are reviewed to assess the scientific evidence of whether BC is a safe and effective antimicrobial and immunomodulatory nutritional supplement that reduces clinical complications related to preterm birth, infections, and gut disorders. Studies in infants and animals suggest that BC should be supplemented at an optimal age, time, and level to be both safe and effective. Exclusive BC feeding is not recommended for infants because of nutritional imbalances relative to human milk. On the other hand, adverse effects, including allergies and intolerance, appear unlikely when BC is provided as a supplement within normal nutrition guidelines for infants and children. Larger clinical trials in infant populations are needed to provide more evidence of health benefits when patients are supplemented with BC in addition to human milk or formula. Igs and other bioactive factors in BC may work in synergy, making it critical to preserve bioactivity with gentle processing and pasteurization methods. BC has the potential to become a safe and effective nutritional supplement for several pediatric subpopulations.

Bovine Colostrum and Its Potential for Human Health and Nutrition

Colostrum is the first milk produced post-partum by mammals and is compositionally distinct from mature milk. Bovine colostrum has a long history of consumption by humans, and there have been a number of studies investigating its potential for applications in human nutrition and health. Extensive characterization of the constituent fractions has identified a wealth of potentially bioactive molecules, their potential for shaping neonatal development, and the potential for their application beyond the neonatal period. Proteins, fats, glycans, minerals, and vitamins are abundant in colostrum, and advances in dairy processing technologies have enabled the advancement of bovine colostrum from relative limitations of a fresh and unprocessed food to a variety of potential applications. In these forms, clinical studies have examined bovine colostrum as having the substantial potential to improve human health. This review discusses the macro-and micronutrient composition of colostrum as well as describing well-characterized bioactives found in bovine colostrum and their potential for human health. Current gaps in knowledge are also identified and future directions are considered in order to elevate the potential for bovine colostrum as a component of a healthy diet for a variety of relevant human populations.

Colostrum Therapy for Human Gastrointestinal Health and Disease

There is increasing awareness that a broad range of gastrointestinal diseases, and some systemic diseases, are characterized by failure of the mucosal barrier. Bovine colostrum is a complex biological fluid replete with growth factors, nutrients, hormones, and paracrine factors which have a range of properties likely to contribute to mucosal healing in a wide range of infective, inflammatory, and injury conditions. In this review, we describe the anatomy and physiology of the intestinal barrier and how it may fail. We survey selected diseases in which disordered barrier function contributes to disease pathogenesis or progression, and review the evidence for or against efficacy of bovine colostrum in management. These disorders include enteropathy due to non-steroidal anti-inflammatory drugs (NSAIDs), inflammatory bowel disease (IBD), necrotizing enterocolitis, infectious diarrhea, intestinal failure, and damage due to cancer therapy. In animal models, bovine colostrum benefits NSAID enteropathy, IBD, and intestinal failure. In human trials, there is substantial evidence of efficacy of bovine colostrum in inflammatory bowel disease and in infectious diarrhea. Given the robust scientific rationale for using bovine colostrum as a promoter of mucosal healing, further work is needed to define its role in therapy.

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection

Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.

Bovine Colostrum in the Treatment of Acute Diarrhea in Children: A Double-Blinded Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of bovine colostrum (BC) on the treatment of children with acute diarrhea attending the outpatient clinic.

METHODS

This double-blind randomized controlled trial was conducted on 160 children with diarrhea; 80 cases were randomly treated with BC group and 80 cases randomly received placebo (placebo group). All cases were investigated for bacterial causes of diarrhea (Salmonella spp, Shigella spp, diarrheagenic E. coli (DEC), Campylobacter spp., and Vibrio cholerae) as well as for Rotavirus antigen in stool.

RESULTS

After 48 h, the BC group had a significantly lower frequency of vomiting, diarrhea and Vesikari scoring compared with the placebo group (p = 0.000, p = 0.000, p = 0.000, respectively), whether it was due to Rotavirus or E. coli infection.

CONCLUSIONS

BC is effective in the treatment of acute diarrhea and can be considered as adjuvant therapy in both viral and bacterial diarrhea to prevent diarrhea-related complications.

Effects of oropharyngeal administration of colostrum on the incidence of necrotizing enterocolitis, late-onset sepsis, and death in preterm infants: a meta-analysis of RCTs

Necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) are two major contributors to death among preterm infants. Oropharyngeal administration of colostrum (OAC) has been proved as an easy, safe, and economically viable technique to help preterm neonates to build up their immunity. In this review, we assessed the effects of OAC on preterm infants. Several mainstream databases were searched including PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and a website of clinical trials. Randomized controlled trials (RCTs) comparing OAC vs. placebo or no intervention in preterm infants (gestation age <34 weeks or birth weight <1500 g) were eligible. Overall, nine RCTs (n = 689) were included in the review. Meta-analysis showed no statistical significance in terms of the incidence of NEC (RR = 0.59, 95% CI = 0.33-1.06, p = 0.08), LOS (RR = 0.78, 95% CI = 0.60-1.03, p = 0.08) and mortality rate (RR = 0.63, 95% CI = 0.38-1.05, p = 0.07). No significant difference was found in the subgroup analysis, apart from the group of the undeveloped region in NEC and mortality. In addition, time was significantly reduced in terms of achieving full enteral feeding (MD = -3.60, 95% CI = -6.55-0.64, p = 0.02) and hospital stay (MD = -10.38, 95% CI = -18.47-2.29, p = 0.01). The results show that OAC does not reduce the incidences of NEC, LOS, and death in preterm infants, but there is a trend toward a positive effect. It is therefore recommended as routine care for preterm infants in the NICU.

Nutritional interventions to reduce rates of infection, necrotizing enterocolitis and mortality in very preterm infants

Observational studies demonstrating reduced rates of infections, necrotizing enterocolitis (NEC), and mortality in preterm infants fed their own mother's milk, as opposed to formula, have prompted endeavors to achieve similar effects with the right choice of food and food additives. In a systematic review of meta-analyses and randomized controlled trials (RCTs), we considered nutritional interventions aimed at reducing the rates of infections, NEC, or mortality in very preterm infants. The overall effects of particular interventions were presented as risk ratios with 95% confidence intervals. In RCTs, pasteurized human donor milk, as opposed to formula, reduced NEC but not infections or mortality. No differences emerged between infants receiving human or bovine milk-based fortifiers. Pooled data of small trials and a recent large RCT suggested that bovine lactoferrin reduced rates of fungal sepsis without impact on other infections, NEC, or mortality. Pooled data of RCTs assessing the use of prebiotic oligosaccharides found reduced infection but not mortality. Enteral L-glutamine (six RCTs) lowered infection rates, and enteral L-arginine (three RCTs) reduced NEC. A meta-analysis sensitivity approach found multiple-strain (but not single-strain) probiotics to be highly effective in reducing NEC and mortality. Thus, selected food components may help to improve outcomes in preterm infants.

An Overview of Systematic Reviews of Randomized-Controlled Trials for Preventing Necrotizing Enterocolitis in Preterm Infants

Necrotizing enterocolitis (NEC) remains a major cause for neonatal mortality and morbidity in preterm infants. The purpose of this review was to summarize evidence from systematic reviews of randomized-controlled trials (RCTs) regarding antenatal and postnatal interventions for preventing NEC. PubMed, EMBASE, the Cochrane Library Databases, Database of Abstracts of Reviews of Effects, and Campbell Library were searched for meta-analyses in which NEC was reported as an outcome after antenatal or postnatal strategies. The AMSTAR instrument was used to evaluate quality of included reviews. Grading of Recommendations, Assessment, Development and Evaluation assessment was used to evaluate certainty of evidence. We identified 98 meta-analyses of RCTs. The quality of included reviews was adequate, whereas the certainty of evidence was moderate to very low. Moderate certainty evidence showed a reduction in NEC following administration of a combination of species of probiotics, probiotics (any), antenatal corticosteroids in pregnant women at risk of preterm birth, and ibuprofen versus indomethacin for treatment of patent ductus arteriosus (PDA). For surgical NEC, moderate certainty evidence showed an increased risk with lower (85-89%) oxygen saturation target levels, compared with higher (91-95%) oxygen saturation target levels. In conclusion, decreased risk of NEC is observed with probiotics, antenatal corticosteroids for women at risk of preterm birth, and ibuprofen versus indomethacin for treatment of PDA. Targeting lower oxygen saturations may increase the risk of surgical NEC, compared to targeting higher saturations.