What are the feeding strategies for deterrence and prevention of necrotizing enterocolitis (NEC)?

Updated: Dec 27, 2017
  • Author: Shelley C Springer, JD, MD, MSc, MBA, FAAP; Chief Editor: Muhammad Aslam, MD  more...
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Breastfed babies have a lower incidence of necrotizing enterocolitis (NEC) than do formula-fed infants, [53, 54] particularly in very low birth weight (VLBW) (≤1500 g) neonates. [55] In a retrospective study of 550 VLBW neonates who received donor human milk, those who received human milk on 50% or more of hospital days had equivalent growth outcomes but significantly lower rates of NEC (3.4% NEC) compared to infants who received human milk on fewer than 50% of hospital days (13.5% NEC). [55] Mortality was also reduced, although this was not a significant difference (1.0% vs 4.2%, respectively).

Much anecdotal evidence details the role of feeding regimens in the etiology of NEC, but clinical research does not demonstrate definitive evidence for either causation or prevention. Although conventional wisdom recommends slow initiation and advancement of enteral feeds for premature infants, random trials do not show an increased incidence of NEC in babies in whom feeds have been started early in life versus after 2 weeks' chronologic age. [56, 57]

McKeown et al reported that rapid increase in feeding volume (>20 mL/kg/d) was associated with higher risk of NEC. [29] Later, however, Rayyis et al showed no difference in the occurrence of NEC Bell stage II or greater in patients advanced at 15 mL/kg/day compared with those advanced at 35 mL/kg/day. [58] Similarly, a systematic review published by the Cochrane Collaboration reported no effect on NEC from rapid feeding advancement for low birth weight infants. [59, 60]

Antenatal and postnatal conditions that diminish intestinal blood flow may increase an infant's risk of developing NEC. Antenatal conditions causing placental insufficiency, such as hypertension, preeclampsia, or cocaine use, may justify a more cautious and vigilant approach to enteral feeding in these infants. Similarly, postnatal conditions that diminish splanchnic blood flow, such as patent ductus arteriosus (particularly when associated with reversed aortic diastolic flow demonstrated on echocardiography), other cardiac disease, or general hypotension/cardiovascular compromise, may increase the risk.

Because early presentation of NEC can be subtle, high clinical suspicion is important when evaluating any infant with signs of feeding intolerance or other abdominal pathology. In general, continuing to feed a baby with developing NEC worsens the disease.

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