Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants

Parthanatos initiated by ROS-induced DNA damage is involved in intestinal epithelial injury during necrotizing enterocolitis

Necrotizing enterocolitis (NEC) involves intestinal epithelial damage and inflammatory response and is associated with high morbidity and mortality in infants. To improve therapeutic prospects, elucidating underlying molecular mechanisms of intestinal epithelial damage during NEC is of the essence. Poly (ADP-ribose) polymerase 1 (PARP1)-dependent parthanatos is a programmed inflammatory cell death. In the present study, the presence of parthanatos-associated proteins PARP1 and poly (ADP-ribose) (PAR), along with high expression of DNA damage-associated biomarkers, 8-hydroxy-2'-deoxyguanosine (8-OHdG) and phosphorylation of histone H2AX (γH2AX), were discovered in the intestinal tissues of NEC infants. Additionally, the upregulated expression of PARP1 and PAR in NEC intestinal tissues correlated distinctly with clinical indices indicative of NEC incidence and severity. Furthermore, we demonstrated that inhibiting the expression of parthanatos-associated proteins, by either pharmacological blockage using 3-aminobenzamide (3-AB), an inhibitor of PARP1, or genetic knockout using Parp1-deficient mice, resulted in substantial improvements in both histopathological severity scores associated with intestinal injury and inflammatory reactions. Moreover, in an in vitro NEC model, reactive oxygen species (ROS)-induced DNA damage promoted the formation of PAR and nuclear translocation of apoptosis-inducing factor (AIF), thus activating PARP1-dependent parthanatos in Caco-2 cells and human intestinal organoids. Our work verifies a previously unexplored role for parthanatos in intestinal epithelial damage during NEC and suggests that inhibition of parthanatos may serve as a potential therapeutic strategy for intervention of NEC.

Safety and Effectiveness of Probiotics in Preterm Infants with Necrotizing Enterocolitis

Although necrotizing enterocolitis is a leading cause of morbidity and mortality among preterm infants, its underlying pathophysiology is not fully understood. Gut dysbiosis, an imbalance between commensal and pathogenic microbes, in the preterm infant is likely a major contributor to the development of necrotizing enterocolitis. In this review, we will discuss the increasing use of probiotics in the NICU, an intervention aimed to mitigate alterations in the gut microbiome. We will review the existing evidence regarding the safety and effectiveness of probiotics, and their potential to reduce rates of necrotizing enterocolitis in preterm infants.

Safety and Effectiveness of Probiotics in Preterm Infants with Necrotizing Enterocolitis

Although necrotizing enterocolitis is a leading cause of morbidity and mortality among preterm infants, its underlying pathophysiology is not fully understood. Gut dysbiosis, an imbalance between commensal and pathogenic microbes, in the preterm infant is likely a major contributor to the development of necrotizing enterocolitis. In this review, we will discuss the increasing use of probiotics in the NICU, an intervention aimed to mitigate alterations in the gut microbiome. We will review the existing evidence regarding the safety and effectiveness of probiotics, and their potential to reduce rates of necrotizing enterocolitis in preterm infants.

Oral administration of bone marrow-derived mesenchymal stem cells attenuates intestinal injury in necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a major cause of morbidity in premature infants. However, effective treatment options for NEC are currently lacking.

PURPOSE

This study aimed to determine the optimal dose of intraperitoneally administered bone marrow-derived mesenchymal stem cells (BM-MSCs) and investigate the therapeutic potential of orally administered BM-MSCs in NEC.

METHODS

Neonatal mice were fed maternal breast milk for the first 2 days of life. On day 3, the neonatal mice were randomly divided into control, negative control, and BM-MSC-treated groups. Lipopolysaccharide (LPS) was administered for 3 days, and cold stress (4°C, 10 minutes) was applied 3 times a day to induce NEC. High-dose (1×106 cells) or low-dose (1×105 cells) BM-MSCs were administered intraperitoneally 1 or 3 times between days 6 and 8 to treat the NEC. The orally administered group received a low dose of BM-MSCs on day 6. Furthermore, except for the control group, intraepithelial cells (IECs) of the small intestine of neonatal mice were treated with LPS and exposed to 5% O2/95% N2 hypoxic stress for 2 hours. Thereafter, each was treated with BM-MSCs.

RESULTS

Tissue injury, apoptosis, and inflammatory marker levels were significantly reduced after BM-MSC administration. Oral administration was as effective as intraperitoneal administration, even at a low dose (1×105 cells) of BM-MSCs. The efficacy of high (1×106 cells) or multiple divided doses of BM-MSCs did not differ from that of low-dose treatment. Significantly improved wound healing was observed after BM-MSC administration to injured IECs.

CONCLUSION

The oral administration of BM-MSCs is a promising treatment option for NEC in infants. Further human studies of BM-MSCs are necessary to determine the optimal dose required to achieve safe and effective outcomes.

Operation Status of the Mutual Aid Human Milk Bank for Preterm Infants and Data Analysis

Objectives

This study aimed to investigate the matching degree between the donated supply and demand, clinical characteristics of both donors and recipients, along with the operation cost.

Methods

From January 1, 2018 to December 31, 2021, the data on human milk donation and usage, the clinical characteristics of donors and recipients, and the cost of each operating center were collected from the Manual Donation Registration Form and Information Management System of the selected human milk bank.

Results

During the four years that the human milk bank was in operation, the volume of donated milk was slightly greater than the volume of consumed milk. A total of 1364 donors donated 2434.63 liters of qualified human milk, for RMB 1,791,000 (USD 257, 202), ie, RMB 385.3 (USD 55.3)/L; 97.8% of the donors were preterm puerperae, and 59% of the donors donated between 1 week and 1 month after delivery. All recipients were preterm infants and received donated human milk for a duration of 9.4 days on average. During the four years of operation, the proportion of donors who had previously received donated milk among all donors showed an overall increasing trend, while the incidence of NEC in preterm infants gradually decreased.

Conclusions

The increasingly optimized structure of donors, the more economical operation, and the fact that the use of donated milk may not affect breastfeeding of the recipients have made it a human milk bank operation mode worthy of promotion.

The impact of maternal stress on the development of necrotizing enterocolitis: A comprehensive review

Necrotizing Enterocolitis (NEC) is a devastating intestinal inflammatory disease with significant morbidity and mortality. Numerous predictors have been implicated in the development of NEC, with a relatively less emphasis on maternal factors. Pregnancy drives women into a new stage of life that increases their susceptibility to biological and psychological stress. Additionally, maternal stress during pregnancy has been linked to various complications that can negatively impact both the mother and the developing fetus. These detrimental effects are facilitated by various systemic modifications. Similarly, there is evidence from animal studies that suggest a relationship between maternal stress and the occurrence of NEC due to the alterations observed in neonates. In this review, we will (1) discuss the physiological and psychological burden of maternal stress and how it can be linked to NEC, (2) summarize various predictors and risk factors of NEC, and (3) discuss the most widely utilized animal models for assessing the effects of prenatal stress on offspring.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

BACKGROUND

Human milk-based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk-based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.

METHODS

Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.

RESULTS

Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution's size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.

CONCLUSIONS

The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

Advancements in neonatology through quality improvement

In the past 3 decades, quality improvement methodology has often been employed in medicine to improve patient outcomes. Neonatal medicine has seen an increase in publications using improvement science to ensure the application of potentially better practices to decrease complications and increase survival without major disability. This article reviews quality improvement studies that have impacted neonatal mortality and morbidity, as well as specific disease processes including bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity. Using improvement science, studies have substantially reduced neonatal mortality and the major complications of preterm birth.

Early erythropoietin for preventing necrotizing enterocolitis in preterm neonates - an updated meta-analysis

Previous systematic reviews suggest reduction in necrotizing enterocolitis (NEC) among preterm infants supplemented with erythropoietin (EPO). We aimed to update our 2018 systematic review in this field considering the evidence accumulated over the last 3 years. Randomized controlled trials (RCTs) reporting the effect of early EPO supplementation vs placebo/no EPO supplementation on any stage NEC in preterm infants were included. Fixed effect model was used for meta-analysis. Trial sequential analysis (TSA) was conducted to verify the effects of EPO on NEC after accounting for repeated significance testing. A total of 22 RCTs (n = 5359) were included, of which six were new (n = 2541 additional preterm infants) in comparison to our previous systematic review. EPO significantly decreased the risk of any stage NEC (232/2669 (8.7%) vs 313/2690 (11.6%); RR: 0·76; TSA adjusted 95% CI (0·64, 0·90); p = 0·0008, number needed to treat (NNT) = 34). The risk of definite NEC (≥ Stage II) was also significantly reduced by EPO administration (105/2219 (4.7%) vs 141/2246 (6.3%); RR: 0.77; 95% CI (0.61, 0.98); p = 0.03, NNT: 62). However, the results for definite NEC were no longer significant on sensitivity analyses that included (a) only double-blind RCTs and (b) only prospectively registered trials. The quality of evidence was deemed moderate-to-low for the reported outcomes.

CONCLUSION

There is moderate to low-quality evidence that early prophylactic EPO reduces any stage and ≥ Stage II NEC in preterm neonates. Prospectively registered, adequately powered, double-blind RCTs are required to confirm these findings.

WHAT IS KNOWN

• Experimental studies have shown that erythropoietin (EPO) has gastrointestinal trophic effects. • Systematic reviews have shown that early treatment with EPO may decrease the risk of gut injury in preterm or low birth weight infants.

WHAT IS NEW

• Early EPO supplementation significantly reduced the incidence of any stage NEC and definite NEC in preterm infants < 34 weeks of gestation. • EPO had no significant effect on definite NEC in the analyses that included only double-blinded and prospectively registered RCTs. How might it impact clinical practice in the foreseeable future? • Early prophylactic EPO can be recommended for NEC prevention if its benefits are consistently demonstrated in adequately powered randomized trials with a low risk of bias.

A quality improvement initiative to standardize time to initiation of enteral feeds after non-surgical necrotizing enterocolitis using a consensus-based guideline

BACKGROUND

Recent evidence demonstrates that earlier feeding may be beneficial after non-surgical necrotizing enterocolitis (NEC). We aimed to decrease time to reach full enteral feeds by 20% post-NEC by standardizing time to reinitiate feeds.

METHODS

We implemented a consensus-based guideline for earlier feeding post-NEC. Outcome measures included days to initiate enteral feeds and reach full enteral feeds. Central venous line days and length of stay were also evaluated. Balancing measures were NEC recurrence and post-NEC stricture. Statistical analysis used process control methodology and standard comparison statistical testing.

RESULTS

Average days infants with Stage II NEC began feeding decreased from 9.4 to 5.1 days and average days to reach full feeds was decreased by 35% from 24.0 to 15.7 days. We observed no change in our balancing measures.

CONCLUSION

A multidisciplinary consensus-based NEC earlier feeding guideline decreased time to reach full enteral feeds and reduced central line days without adverse events.

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths

OBJECTIVE

The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants.

STUDY DESIGN

A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality.

RESULTS

Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change.

CONCLUSION

A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC.

KEY POINTS

· QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Low technology, mild controlled hypothermia for necrotizing enterocolitis treatment: an initiative to improve healthcare to preterm neonates

Necrotizing enterocolitis (NEC) treatment remains unchanged for years. Data suggest that mild controlled hypothermia could potentially improve NEC outcomes. Our units presented unfavourable outcomes on NEC. The aim was to assess our experience with low technology, mild controlled hypothermia on NEC outcomes, and improve preterm infants' healthcare. This was a single-center quality improvement study with retrospective cohort design at the neonatal intensive care unit in the university hospital. Forty-three preterm infants with NEC (Modified Bell's Stage II/III) were included: 19 in the control group (2015-2018) and 24 in the hypothermia group (2018-2020). The control group received standard treatment (fasting, abdominal decompression, and broad-spectrum antibiotics). The hypothermia group underwent cooling to 35.5 °C for 48 h after NEC diagnosis, along with conventional treatment. The primary outcomes are intestinal perforation, need for surgery, duration of parenteral nutrition, death, and extensive resection of the small intestine. There was no statistical difference in the NEC score. The hypothermia group required less surgery (aRR 0.40; 95% CI 0.19-0.85), presented less bowel perforation (aRR 0.39; 95% CI 0.18; 0.83), had a shorter duration of parenteral nutrition (aHR 5.28; 95% CI 1.88-14.89), did not need extensive intestinal resection, (0 vs 15.7%), and did not experience any deaths (0 vs 31.6%).Conclusions: In our experience, low technology, mild controlled hypothermia was feasible, not related to adverse effects, and effective treatment for NEC Modified Bell's Stage II/III. It avoided surgery, bowel perforation, and extensive intestinal resection; reduced mortality; and shortened parenteral nutrition duration. What is Known: • New approaches have been proposed to avoid enterocolitis incidence; however, the treatment of enterocolitis stage 2 has been the same for decades, and unfavourable outcomes remain despite conventional management. • Studies suggest that hypothermia can be an alternative to enterocolitis treatment. What is New: • Mild controlled hypothermia can be an additional practice to treat enterocolitis stage 2, is feasible, and is not related to adverse effects to preterm infants. • It can decrease surgery needs, duration of parenteral nutrition, and death and avoids extensive intestinal resection in preterm infants.

Feasibility and Acceptability of a Neonatal Project ECHO (NeoECHO) as a Dissemination and Implementation Strategy to Prevent Necrotizing Enterocolitis

BACKGROUND

Caregivers in the neonatal intensive care unit (NICU) often determine care practices in silos, although access to learning communities can improve quality. Project ECHO, a telehealth-delivered mentoring intervention, provides specialists' expertise but not in the NICU until now. Necrotizing enterocolitis (NEC) prevention and timely recognition is one area where specialist support and engaging with a learning community could improve outcomes. NEC-Zero is one care bundle that aims to improve care quality by providing tools to implement NEC prevention in family-engaged ways.

AIMS

To examine the feasibility and acceptability of NeoECHO to disseminate NEC-Zero education and describe the intentions of internal facilitators (IFs) and clinicians to initiate quality improvement changes.

METHODS

This was a convergent mixed-methods study. Our team delivered the first neonatal adaptation of Project ECHO called "NeoECHO" to leverage facilitation as an implementation strategy to disseminate NEC-Zero evidence and support practice change.

RESULTS

Six IFs and seven NICUs participated. All units and IFs that began the series finished it. Of the 261 session attendees, 206 (79%) study evaluations were completed. Of those who completed evaluations, 89 (100%) completed at least one session and 29 (33%) completed three or more. Satisfaction was high. Participants appreciated the engaged and accessible format to learn from experts using real case examples and didactic sessions. Individuals and IFs reported intentions to adopt evidence based on NeoECHO.

LINKING EVIDENCE TO ACTION

NeoECHO was an acceptable and feasible way to engage under-resourced NICUs and share NEC-Zero evidence and tools. More research is needed to examine the impact of NeoECHO on care processes and patient outcomes.

Outcomes of Neonates Requiring Neonatal Intensive Care Admission for Necrotizing Enterocolitis in a Resource-Restricted Hospital in Cape Town, South Africa

AIM

The aim of this study is to describe the 30-day mortality, neurodevelopmental outcome and composite outcome (mortality or abnormal neurodevelopmental outcome) of neonates with necrotizing enterocolitis (NEC), requiring neonatal intensive care (NICU) admission, in a resource-restricted environment.

METHODS

All neonates admitted to Tygerberg Hospital, NICU, with a presumptive diagnosis of NEC Bell stage IIB or more, over a 5-year period, were included.

RESULTS

One hundred and thirty-five neonates were included with a mean gestational age of 29 ± 2.7 weeks and mean birth weight of 1185 g ± 446 g. The 30-day mortality was 52%, neurodevelopment abnormalities occurred in 35% of survivors and adverse composite outcome in 63%. The 30-day mortality and adverse composite outcome risk were increased by small for gestational age, shock, metabolic acidosis, inotrope requirement and first feed >9 days after surgery.

CONCLUSION

In resource-restricted environments, mortality and abnormal neurodevelopmental outcome of neonates with NEC, remain high. However, outcomes are comparable with international literature. Neonates with NEC, requiring NICU admission and surgery, require neurodevelopmental follow-up.

Grading the evidence to identify strategies to modify risk for necrotizing enterocolitis

Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.

Probiotic Use and Safety in the Neonatal Intensive Care Unit: A Matched Cohort Study

OBJECTIVE

To determine the prevalence of probiotic administration in infants born preterm over time, as well as the association between probiotic administration and select adverse outcomes.

STUDY DESIGN

We performed a multicenter cohort study of infants 23-29 weeks of gestational age admitted to 289 neonatal intensive care units from 1997 to 2016. We evaluated the type of probiotics given and prevalence of exposure to probiotics over time and by site. We matched infants exposed to probiotics by several factors to unexposed infants receiving enteral feeds on the same postnatal day. We performed conditional logistic regression to evaluate the association between probiotics exposure and adverse outcomes, including necrotizing enterocolitis (NEC), bloodstream infections, meningitis, and death.

RESULTS

Of 78 076 infants, 3626 (4.6%) received probiotics. Probiotic use increased over the study period and varied among neonatal intensive care units. We matched 2178 infants exposed to probiotics to 33 807 without exposure. Probiotic administration was associated with a decrease in NEC (OR 0.62, 95% CI 0.48-0.80) and death (OR 0.52, 95% CI 0.39-0.70), an increase in Candida infection (OR 2.23, 95% CI 1.29-3.85), but no increase in bloodstream infection (OR 0.86, 95% CI 0.70-1.05) or meningitis (OR 1.18, 95% CI 0.40-3.46).

CONCLUSIONS

Probiotic use increased over time and was associated with decreased odds of NEC and death. Prospective, randomized-controlled studies of specific probiotic products are needed to further investigate the safety and efficacy of probiotics in preterm infants.

Transfusion-related Gut Injury and Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) accounts for 10% of deaths in neonatal intensive care units. Several causal mechanisms are likely to lead to a final common disease phenotype. This article summarizes recent data on NEC following red blood cell (RBC) transfusion, with a focus on the most recent literature and ongoing trials. It highlights potential mechanisms from preclinical and human physiologic studies. It also discusses the role of feeding during RBC transfusion and the risk of NEC. Ongoing randomized trials will provide important data on how liberal or conservative approaches to RBC transfusion influence the risk of NEC.

Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: A multicenter cohort analysis

OBJECTIVE

We sought to describe changes in the incidence and mortality of necrotizing enterocolitis (NEC) and associated surgical management strategies for very low birth weight (VLBW) infants.

METHODS

Data were prospectively collected on VLBW infants (≤1500 g or < 29 weeks) born 2006 to 2017 and admitted to 820 U.S. centers. NEC was defined by the presence of at least one clinical and one radiographic finding. Trends analyses were performed to assess changes in incidence and mortality over time.

RESULTS

Of 473,895 VLBW infants, 36,130 (7.6%) were diagnosed with NEC, of which 21,051 (58.3%) had medical NEC and 15,079 (41.7%) had surgical NEC. Medical NEC decreased from 5.3% to 3.0% (p < 0.0001). Surgical NEC decreased from 3.4% to 3.1% (p = 0.06). Medical NEC mortality decreased from 20.7% to 16.8% (p = 0.003), while surgical NEC mortality decreased from 36.6% to 31.6% (p < 0.0001). In the surgical cohort, the use of primary peritoneal drainage (PPD) versus initial laparotomy rose from 23.2% to 46.8%.

CONCLUSION

The incidence and mortality of both medical and surgical NEC have decreased over time. Changes in surgical management during this time period included the increased utilization of primary peritoneal drainage.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

A randomized controlled trial protocol comparing the feeds of fresh versus frozen mother's own milk for preterm infants in the NICU

Background

Necrotizing enterocolitis (NEC) is the leading cause of death among preterm infants born at < 30 weeks’ gestation. The incidence of NEC is reduced when infants are fed human milk. However, in many neonatal intensive care units (NICUs), it is standard practice to freeze and/or pasteurize human milk, which deactivates bioactive components that may offer additional protective benefits. Indeed, our pilot study showed that one feed of fresh mother’s own milk per day was safe, feasible, and can reduce morbidity in preterm infants. To further evaluate the benefits of fresh human milk in the NICU, a randomized controlled trial is needed.

Methods

Our prospective multicenter, double-blinded, randomized, controlled trial will include infants born at < 30 weeks’ gestation and admitted to one of 29 tertiary NICUs in China. Infants in the intervention (fresh human milk) group (n = 1549) will receive at least two feeds of fresh human milk (i.e., within 4 h of expression) per day from the time of enrollment until 32 weeks’ corrected age or discharge to home. Infants in the control group (n = 1549) will receive previously frozen human milk following the current standard protocols. Following informed consent, enrolled infants will be randomly allocated to the control or fresh human milk groups. The primary outcome is the composite outcome mortality or NEC ≥ stage 2 at 32 weeks’ corrected age, and the secondary outcomes are mortality, NEC ≥ stage 2, NEC needing surgery, late-onset sepsis, retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), weight gain, change in weight, increase in length, increase in head circumference, time to full enteral feeds, and finally, the number and type of critical incident reports, including feeding errors.

Discussion

Our double-blinded, randomized, controlled trial aims to examine whether fresh human milk can improve infant outcomes. The results of this study will impact both Chinese and international medical practice and feeding policy for preterm infants. In addition, data from our study will inform changes in health policy in NICUs across China, such that mothers are encouraged to enter the NICU and express fresh milk for their infants.

Trial registration

Chinese Clinical Trial Registry; #ChiCTR1900020577; registered January 1, 2019; http://www.chictr.org.cn/showprojen.aspx?proj=34276

Ulinastatin Reduces the Severity of Intestinal Damage in the Neonatal Rat Model of Necrotizing Enterocolitis

Background

Ulinastatin is a protease inhibitor derived from urine that has shown anti-inflammatory effects in human disease, including in sepsis. Necrotizing enterocolitis (NEC) is a common gastrointestinal disease in premature infants. Our aim was to explore the effects of ulinastatin on a neonatal NEC rat model.

Material/Methods

Forty-five neonatal rats were divided into 3 groups: normal control; NEC+sepsis-induced kidney injury (SIRS); NEC/SIRS+ulinastatin. The NEC/SIRS model was induced by injection of intraperitoneal saline, enteral formula feeding, hypoxia-hyperoxide, and cold stress exposure. The NEC/SIRS neonatal rats were perfused with ulinastatin at a dose of 10 000 u/kg/day. Giemsa staining and hematoxylin and eosin (H&E) were performed to evaluate the severity of intestinal damage. To assess intestinal cell apoptosis, we examined the expression of caspase-3 by TUNEL staining and western blot analysis. Intestinal levels of inflammatory cytokines (IL-1β, IL-6, and TNF-α) were examined using ELISA assay.

Results

Rats in the NEC treated with ulinastatin group had better physiological status and histological score compared to the NEC/SIRS group. Ulinastatin reduced NEC-induced weight loss. Macroscopic and microscopic morphology analyses showed that rats in the NEC treated with ulinastatin group had lower severity of intestinal damage compared to the NEC/SIRS group. TUNEL staining and caspase-3 expression detection results revealed that ulinastatin significantly inhibited intestinal cell apoptosis of NEC. Furthermore, ulinastatin decreased the intestinal levels of IL-1β, IL-6, and TNF-α in NEC.

Conclusions

Ulinastatin could ameliorate the severity of intestinal damage in NEC and possess anti-apoptosis and anti-inflammation effects.

Retrospective review of neonatal morbidity and mortality at public referral hospitals in Greater Accra Region of Ghana:2013-2014

BACKGROUND

Reliable local data for evaluating and planning neonatal interventions in low-resource countries are scarce. To provide data for evaluating neonatal interventions in an administrative region of Ghana, the study examined baseline data for inpatient neonatal services prior to the implementation of a 5-years national action plan to reduce newborn deaths.

METHODS

This is a retrospective review of admissions and deaths registry for the years 2013 and 2014 at 3 referral neonatal units representing district, regional and tertiary referral centres in Greater Accra Region of Ghana. Perinatal, and neonatal hospitalisation data were extracted. Chi-squared test was used to compare outcomes.

RESULTS

Of the 8228 newborn infants hospitalised for special care, over 99% had antenatal care and were delivered at a health facility, 96.7% and 91.7% had birth weight and outcome data, respectively. Low birth weight infants accounted for 48.5% of total admissions and 67% of deaths. Using birth weight criteria, survival to discharge was 25.6% for infants less than 1000grams, 67.9% for 1000-1499grams, 88% for 1500-2499grams and 88.7% for infants 2500grams and higher. Among infants with birth weight of 1000grams and higher, perinatal asphyxia (70.6%) and respiratory distress (16.4%) accounted for most deaths.

CONCLUSION

There was significant burden of neonatal morbidity and mortality in hospitalized newborns prior to the implementation of the national action plan. The report provides a yardstick for assessing the impact of the national action plan and comparative analysis of future interventions on neonatal outcome in the region.

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units

BACKGROUND

Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%.

PURPOSE

This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC.

METHODS

A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs.

RESULTS

NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003).

IMPLICATIONS FOR PRACTICE

Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount.

IMPLICATIONS FOR RESEARCH

Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.

Vermont Oxford Network: a worldwide learning community

A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.

Feeding during transfusion and the risk of necrotizing enterocolitis in preterm infants

OBJECTIVE

To evaluate the effect of withholding feeds during transfusion on transfusion associated acute gut injury (TRAGI).

STUDY DESIGN

Data were collected on 125 preterm infants before and after the practice of withholding feeds for 12-24 h during transfusion was instituted. Logistic regression was used to examine effects of withholding feeds on TRAGI rates.

RESULTS

A total of 19 (15%) infants developed NEC; 6/19 (32%) had TRAGI. Postnatal hydrocortisone use was associated with TRAGI (OR 8.97; 95% CI 1.17-68.46, p = 0.034). There was no difference in NEC rates (15.8 vs. 14.7%) and the proportions (22.2 vs. 40%) of TRAGI in the two time periods before and after instituting the standardized feeding regimen and practice of holding feeds during transfusion.

CONCLUSION

No significant decrease was noted in the rates of TRAGI after feeds were withheld during transfusion. Further studies are warranted to explore the relationship between feeds during transfusion and NEC.

New insights into necrotizing enterocolitis: From laboratory observation to personalized prevention and treatment

BACKGROUND/PURPOSE

Necrotizing enterocolitis (NEC) is a devastating disease of prematurity that develops after feeding, often without warning, and results in diffuse intestinal necrosis leading to sepsis and death in many cases. The lack of improvement in overall survival is influenced by nonspecific diagnostic modalities as well as inexact and nonpersonalized treatment strategies.

METHODS/RESULTS

Recently, we and others have shown that NEC develops in response to exaggerated bacterial signaling in the premature intestine, as a consequence of elevated expression and activity of the bacterial receptor toll-like receptor 4 (TLR4), which is important for normal gut development. Breast milk is a powerful TLR4 inhibitor, while mutations in TLR4 genes lead to increased NEC risk in humans, providing proof-of-concept for its role in NEC. Recently, a drug discovery approach has revealed a novel class of TLR4 inhibitors which are being developed for personalized approaches to NEC treatment.

CONCLUSION

This review will highlight the current understanding of the role of bacterial signaling in NEC pathogenesis, and will describe advances in diagnosis, prevention and treatment of NEC that may hopefully improve survival for these most fragile patients.

SYSTEMATIC REVIEW

Level of Evidence: Level II.

Closing the Gap Between Recommended and Actual Human Milk Use for Fragile Infants: What Will It Take to Overcome Disparities?

This article describes the components of human milk and their value to reduce risk for necrotizing enterocolitis, disparities in access to human milk, potential relationships to care practices within the neonatal intensive care unit, and ways to overcome the disparity.

Modifiable Risk Factors in Necrotizing Enterocolitis

Multicenter groups have reported reductions in the incidence of necrotizing enterocolitis (NEC) among preterm infants over the past 2 decades. These large-scale prevalence studies have coincided with reports from multicenter consortia and single centers of modifications in practice using quality-improvement techniques aimed at either reducing NEC risk specifically or reducing risk of mortality and multiple morbidities associated with extreme prematurity. The modifications in practice have been based on mechanistic studies, epidemiologic association data, and clinical trials. Recent reports from centers modifying practice to reduce NEC are reviewed and select modified/modifiable practices discussed.

Estimation of Neonatal Intestinal Perforation Associated with Necrotizing Enterocolitis by Machine Learning Reveals New Key Factors

Intestinal perforation (IP) associated with necrotizing enterocolitis (NEC) is one of the leading causes of mortality in premature neonates; with major nutritional and neurodevelopmental sequelae. Since predicting which neonates will develop perforation is still challenging; clinicians might benefit considerably with an early diagnosis tool and the identification of critical factors. The aim of this study was to forecast IP related to NEC and to investigate the predictive quality of variables; based on a machine learning-based technique. The Back-propagation neural network was used to train and test the models with a dataset constructed from medical records of the NICU; with birth and hospitalization maternal and neonatal clinical; feeding and laboratory parameters; as input variables. The outcome of the models was diagnosis: (1) IP associated with NEC; (2) NEC or (3) control (neither IP nor NEC). Models accurately estimated IP with good performances; the regression coefficients between the experimental and predicted data were R² > 0.97. Critical variables for IP prediction were identified: neonatal platelets and neutrophils; orotracheal intubation; birth weight; sex; arterial blood gas parameters (pCO₂ and HCO₃); gestational age; use of fortifier; patent ductus arteriosus; maternal age and maternal morbidity. These models may allow quality improvement in medical practice.

The History and State of Neonatal Nursing Quality Improvement Practice and Education

Quality improvement has evolved rapidly in neonatal nursing. This review outlines the history and current state of quality improvement practice and education in neonatal nursing. The future of neonatal nursing includes a stronger emphasis on quality improvement in advanced practice education that promotes doctoral projects that result in clinical improvements. A collective focus will ensure that neonatal nurses not only deliver evidence-based care, but also continually improve the care they deliver.

Newborn infants' hair cortisol levels reflect chronic maternal stress during pregnancy

Cortisol obtained from hair samples represents a retrospective biomarker of chronic stress experienced by the subject in previous months. Although hair cortisol levels have been used to study the relationship between maternal and neonatal stress levels in primates, this has not yet been performed in humans using a longitudinal design and focusing specifically on this association. Therefore, the objective of this study was to determine whether a relationship existed between maternal psychological stress and hair cortisol levels during pregnancy and postpartum, and neonatal hair cortisol levels. The sample consisted of 80 pregnant women and their 80 newborn infants. We conducted a longitudinal assessment of hair cortisol levels, psychological stress, anxiety, and depression in the three trimesters of pregnancy and postpartum. After childbirth, neonatal hair cortisol levels were also measured. We found that maternal hair cortisol levels in the first trimester negatively predicted neonatal hair cortisol levels. Perceived stress in the third trimester of pregnancy also predicted lower neonatal cortisol, whereas pregnancy-specific stress in the same trimester had a positive relation with neonatal cortisol. Cortisol is essential for embryonic and fetal development; consequently, if fetal synthesis of cortisol is affected by high maternal cortisol levels, such development could be impaired.

Implementing Standardized Feeding Guidelines, Challenges, and Results

PURPOSE

The purpose of this article was to develop standardized nutritional guidelines that would promote increased growth velocity (GV) in premature infants.

DESIGN

Evidence-based standardized nutritional guidelines were developed. Guidelines included total parenteral nutrition advancement; enteral feeding advancement; and a bedside nurse gastric residual management algorithm. Staff education was given. Guideline compliance was measured. Nutritional intake and daily weights were recorded.

SAMPLE

Infants of birth weight <1,500 grams who were admitted to the NICU before day of life four.

MAIN OUTCOME VARIABLE

Increase in GV from 12 to 15 g/kg/d.

RESULTS

Growth velocity was unchanged. Compliance to the nutritional guidelines was 70 percent. No difference was seen in length of stay. Rate of necrotizing enterocolitis was decreased.

Toll-Like Receptor-Mediated Intestinal Inflammatory Imbalance in the Pathogenesis of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) remains the leading cause of death from gastrointestinal disease in premature infants and attacks the most fragile patients at a time when they appear to be the most stable. Despite significant advances in our overall care of the premature infant, NEC mortality remains stubbornly high. There is no specific treatment for NEC beyond broad-spectrum antibiotics and intestinal resection, and current efforts have focused on preventive strategies. Over the past decade, we have proposed a unifying hypothesis to explain the pathogenesis of NEC in premature infants that suggests that NEC develops in response to an imbalance between exaggerated proinflammatory signaling in the mucosa of the premature gut leading to mucosal injury, which is not countered effectively by endogenous repair processes, and in the setting of impaired mesenteric perfusion leads to intestinal ischemia and disease development. One of the most important pathways that mediates the balance between injury and repair in the premature intestine, and that plays a key role in NEC pathogenesis, is Toll-like receptor 4 (TLR4), which recognizes lipopolysaccharide on gram-negative bacteria. This review focuses on the role that the TLR4-mediated imbalance between proinflammatory and anti-inflammatory signaling in the premature intestinal epithelium leads to the development of NEC, and will explore how an understanding of the role of TLR4 in NEC pathogenesis has led to the identification of novel preventive or treatment approaches for this devastating disease.

Anemia, red blood cell transfusions, and necrotizing enterocolitis

In the past 15 years, multiple clinical studies have identified a temporal association between red blood cell (RBC) transfusions and necrotizing enterocolitis (NEC). With some variability, most of these studies indicate that up to one-third of all cases of NEC involving very low-birth weight infants may occur within 24-48h after receiving a RBC transfusion. There is also evidence that the risk of such transfusion-associated NEC may be higher in infants transfused with the greatest severity of anemia. In this article, we summarize the clinical evidence pertaining to these issues; specifically, the contribution of RBC transfusions, and the contribution of severity of underlying anemia, to the pathogenesis of a type of NEC potentially termed, "transfusion/anemia-associated NEC."

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.

Improved referral and survival of newborns after scaling up of intensive care in Suriname

BACKGROUND

Scaling up neonatal care facilities in developing countries can improve survival of newborns. Recently, the only tertiary neonatal care facility in Suriname transitioned to a modern environment in which interventions to improve intensive care were performed. This study evaluates impact of this transition on referral pattern and outcomes of newborns.

METHODS

A retrospective chart study amongst newborns admitted to the facility was performed and outcomes of newborns between two 9-month periods before and after the transition in March 2015 were compared.

RESULTS

After the transition more intensive care was delivered (RR 1.23; 95% CI 1.07-1.42) and more outborn newborns were treated (RR 2.02; 95% CI 1.39-2.95) with similar birth weight in both periods (P=0.16). Mortality of inborn and outborn newborns was reduced (RR 0.62; 95% CI 0.41-0.94), along with mortality of sepsis (RR 0.37; 95% CI 0.17-0.81) and asphyxia (RR 0.21; 95% CI 0.51-0.87). Mortality of newborns with a birth weight <1000 grams (34.8%; RR 0.90; 95% CI 0.43-1.90) and incidence of sepsis (38.8%, 95% CI 33.3-44.6) and necrotizing enterocolitis (NEC) (12.5%, 95% CI 6.2-23.6) remained high after the transition.

CONCLUSIONS

After scaling up intensive care at our neonatal care facility more outborn newborns were admitted and survival improved for both in- and outborn newborns. Challenges ahead are sustainability, further improvement of tertiary function, and prevention of NEC and sepsis.

Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants

OBJECTIVE

Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC.

STUDY DESIGN

An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds).

RESULTS

Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score.

CONCLUSIONS

Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.

Enteric serotonin and oxytocin: endogenous regulation of severity in a murine model of necrotizing enterocolitis

Necrotizing enterocolitis (NEC), a gastrointestinal inflammatory disease of unknown etiology that may also affect the liver, causes a great deal of morbidity and mortality in premature infants. We tested the hypothesis that signaling molecules, which are endogenous to the bowel, regulate the severity of intestinal and hepatic damage in an established murine NEC model. Specifically, we postulated that mucosal serotonin (5-HT), which is proinflammatory, would exacerbate experimental NEC and that oxytocin (OT), which is present in enteric neurons and is anti-inflammatory, would oppose it. Genetic deletion of the 5-HT transporter (SERT), which increases and prolongs effects of 5-HT, was found to increase the severity of systemic manifestations, intestinal inflammation, and associated hepatotoxicity of experimental NEC. In contrast, genetic deletion of tryptophan hydroxylase 1 (TPH1), which is responsible for 5-HT biosynthesis in enterochromaffin (EC) cells of the intestinal mucosa, and TPH inhibition with LP-920540 both decrease the severity of experimental NEC in the small intestine and liver. These observations suggest that 5-HT from EC cells helps to drive the inflammatory damage to the gut and liver that occurs in the murine NEC model. Administration of OT decreased, while the OT receptor antagonist atosiban exacerbated, the intestinal inflammation of experimental NEC. Data from the current investigation are consistent with the tested hypotheses-that the enteric signaling molecules, 5-HT (positively) and OT (negatively) regulate severity of inflammation in a mouse model of NEC. Moreover, we suggest that mucosally restricted inhibition of 5-HT biosynthesis and/or administration of OT may be useful in the treatment of NEC.NEW & NOTEWORTHY Serotonin (5-HT) and oxytocin reciprocally regulate the severity of intestinal inflammation and hepatotoxicity in a murine model of necrotizing enterocolitis (NEC). Selective depletion of mucosal 5-HT through genetic deletion or inhibition of tryptophan hydroxylase-1 ameliorates, while deletion of the 5-HT uptake transporter, which increases 5-HT availability, exacerbates the severity of NEC. In contrast, oxytocin reduces, while the oxytocin receptor antagonist atosiban enhances, NEC severity. Peripheral tryptophan hydroxylase inhibition may be useful in treatment of NEC.

Nutritional strategies and gut microbiota composition as risk factors for necrotizing enterocolitis in very-preterm infants

Background: The pathophysiology of necrotizing enterocolitis (NEC) remains poorly understood.Objective: We assessed the relation between feeding strategies, intestinal microbiota composition, and the development of NEC.Design: We performed a prospective nationwide population-based study, EPIPAGE 2 (Etude Epidémiologique sur les Petits Ages Gestationnels), including preterm infants born at <32 wk of gestation in France in 2011. From individual characteristics observed during the first week of life, we calculated a propensity score for the risk of NEC (Bell's stage 2 or 3) after day 7 of life. We analyzed the relation between neonatal intensive care unit (NICU) strategies concerning the rate of progression of enteral feeding, the direct-breastfeeding policy, and the onset of NEC using general linear mixed models to account for clustering by the NICU. An ancillary propensity-matched case-control study, EPIFLORE (Etude Epidémiologique de la flore), in 20 of the 64 NICUs, analyzed the intestinal microbiota by culture and 16S ribosomal RNA gene sequencing.Results: Among the 3161 enrolled preterm infants, 106 (3.4%; 95% CI: 2.8%, 4.0%) developed NEC. Individual characteristics were significantly associated with NEC. Slower and intermediate rates of progression of enteral feeding strategies were associated with a higher risk of NEC, with an adjusted OR of 2.3 (95% CI: 1.2, 4.5; P = 0.01) and 2.0 (95% CI: 1.1, 3.5; P = 0.02), respectively. Less favorable and intermediate direct-breastfeeding policies were associated with higher NEC risk as well, with an adjusted OR of 2.5 (95% CI: 1.1, 5.8; P = 0.03) and 2.3 (95% CI: 1.1, 4.8; P = 0.02), respectively. Microbiota analysis performed in 16 cases and 78 controls showed an association between Clostridium neonatale and Staphylococcus aureus with NEC (P = 0.001 and P = 0.002).Conclusions: A slow rate of progression of enteral feeding and a less favorable direct-breastfeeding policy are associated with an increased risk of developing NEC. For a given level of risk assessed by propensity score, colonization by C. neonatale and/or S. aureus is significantly associated with NEC. This trial (EPIFLORE study) was registered at clinicaltrials.gov as NCT01127698.

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.

Transient effects of transfusion and feeding advances (volumetric and caloric) on necrotizing enterocolitis development: A case-crossover study

Objective

To evaluate the short-term effects of feed fortification, feed volume increase, and PRBC transfusion on the odds of developing NEC.

Study design

Case-crossover study of neonatal intensive care infants born at ≤ 32 weeks’ gestation who were admitted to 5 central Ohio intensive care units from January 2012-July 2016 and developed NEC Bell Stage ≥2. Each patient served as their own control, with exposure during the 48-hour period just prior to NEC onset (hazard period) being compared to a preceding 48-hour control period, thus eliminating confounding by patient factors fixed between both intervals. NEC onset was determined by chart review as the earliest occurrence of one of the following within 24 hours of confirmatory x-ray: (1) antibiotic initiation, (2) enteral feeding cessation, (3) physician first notified of abdominal concerns, or (4) abdominal x-ray ordered. Conditional logistic regression compared exposures to feed volume increase, fortification, and PRBC transfusion during the 48-hour period prior to NEC onset to those during a preceding 48-hour control period. Analyses were stratified by gestational age and anemia (defined: hemoglobin ≤ 9.3 g/dL within 7 days of NEC onset).

Results

We included 63 infants with confirmed NEC. Acute exposure to fortification (odds ratio [OR]: 1.67, 95% confidence interval [CI]: 0.61, 4.59), feed volume increase (OR: 0.63, 95% CI: 0.28, 1.38), and PRBC transfusion (OR: 1.80, 95% CI: 0.60, 5.37) was not associated with the onset of NEC. Gestational age and anemia did not significantly modify the associations. Sensitivity testing substituting 24- and 72-hour hazard and control periods produced similar results.

Conclusion

Using a case-crossover design, we did not detect an association between NEC development and feed fortification, feed volume increase, or PRBC transfusion within 48-hours prior to NEC-onset. Replication in a larger set of cases is needed.

Does quality improvement work in neonatology improve clinical outcomes?

PURPOSE OF REVIEW

Quality improvement initiatives in neonatology have been promoted as an important way of improving outcomes of newborns. The purpose of this review is to examine the effectiveness of recent quality improvement work in improving the outcomes of infants requiring neonatal intensive care.

RECENT FINDINGS

Quality improvement collaboratives and single-center projects demonstrate improvement of clinical processes and outcomes in neonatology that impact both preterm and term infants. Declines in morbidities, resource use, and length of stay have been associated with reductions in healthcare costs.

SUMMARY

Recent quality improvement work has shown evidence of improvement in clinical outcomes in neonatal intensive care patients. These improvements have important implications for the reduction of healthcare costs in this population.

Tools and methods for quality improvement and patient safety in perinatal care

The quality of health care is now recognized to vary widely in all medical specialties, including perinatal medicine. A national focus on quality improvement (QI) and patient safety is prompting providers to change and improve the care given to patients. All QI and safety efforts require the use of an improvement model to manage the complex process of improving care. This article reviews the most common frameworks in use today, including the Model for Improvement, Six Sigma, and Lean. Specific tools such as affinity, key driver and fishbone diagrams, process maps and statistical process control, as well as checklists are reviewed, with examples from the perinatal literature to illustrate their use in perinatal QI efforts.