How to Reduce Necrotizing Enterocolitis in the NICU

In 2011, a quality improvement team at Nationwide Children’s Hospital developed a short list of simple, economical strategies to limit necrotizing enterocolitis (NEC), one of the leading causes of morbidity and mortality in its associated neonatal intensive care units (NICUs).

And those simple strategies worked remarkably well, according to a recent study published in Pediatrics detailing the initiative.

The 26-month QI initiative led to a decrease in the rate of NEC from 8 percent to only 3.1 percent among very low birthweight babies (19 of 606). Very low birthweight was classified as ≤ 1500g and ≤ 28 weeks corrected gestational age.

In addition, NEC-related mortality decreased from 2.7 percent at baseline to 0.9 percent during the study period.

“Any NICU anywhere, at any level of hospital, can do this,” says Maria M. Talavera, DO, a member of the Section of Neonatology at Nationwide Children’s and lead author of the study. “Compared with many interventions in our field, these are easy.”

The QI team included specialists from Neonatology, Pediatric Surgery and Infectious Diseases, as well as clinical pharmacists, dieticians and QI experts. The team chose to implement these three strategies:

1. Early human milk feedings. Mother’s milk, rich in antibodies and healthy bacteria, would be introduced within the first three days of life. These first minimal trophic feedings (10 mg/per kg of weight/per day) would be increased over time to full nutritive feedings.
2. No feedings during blood product transfusions. Being fed during transfusions has been associated with development of NEC, and reducing the metabolic demand on the gut may help. In the cases of indomethacin therapy for patent ductus arteriosis, infants were kept nil per os (NPO) or on minimal feeds.
3. Restricting the use of the acid suppressive medication ranitidine. A number of studies have linked ranitidine with infection and NEC.

From the perspective of 2016, strategies #1 and #3 seem particularly common-sense, says Dr. Talavera, who is also an assistant professor of Pediatrics at The Ohio State University College of Medicine. The connection between some acid suppressive medications and NEC has become even clearer in the years since the QI project began, for example.

While the Nationwide Children’s team continues to believe that strategy #2 is the best for its associated NICUs, other specialists may reasonably argue that holding feeds before or after transfusion – along with holding them during transfusion – would work better in their units, Dr. Talavera says. Reducing demand on the gut is still the goal in any of those variations.

Neonatal Services at Nationwide Children’s is a joint effort between Nationwide Children’s and six maternity hospitals in Central Ohio. Coordinating a QI project among so many different locations can be difficult logistically. The relative simplicity of these interventions, though, meant everyone bought in quickly.

“Because of our size, we see more babies with NEC than many other hospitals, and the sickest babies are transferred to us,” says Dr. Talavera. “If we can implement these strategies, others can too.”

Reference:

Talavera MM, Bixler G, Cozzi C, Dail J, Miller RR, McClead R Jr, Reber K. Quality improvement initiative to reduce the necrotizing enterocolitis rate in premature infants. Pediatrics. 2016 May;137(5).

This study has been supported in part by Award Number Grant UL1TR001070 from the National Center For Advancing Translational Sciences.