Prevention & Nutrition

Necrotizing enterocolitis has been a difficult condition to research due to the complex and multifactorial nature of its pathogenesis. As the major risk factors are bacterial colonisation of immature intestines and NEC rarely occurs in babies who have not been fed, types of feeds and whether, and how, they are causative or protective have been a core area of research.

NEC is up to six times more common in infants fed formula versus breast milk, and in his presentation, Is NEC requiring surgery precipitated by a change in feeds? Observations from 50 consecutive cases, David Burge, Consultant Paediatric and Neonatal Surgeon at University Hospital Southampton, argued that cow’s milk protein products may cause NEC via a non-IgE mediated CMPA mechanism.

Considerable research into breast milk has been undertaken, but as Ruurd van Elburg, Professor of Early Life Nutrition at Emma Children’s Hospital in Amsterdam, emphasised in New insights in human milk composition and benefits for preterm infants, there is not just one human milk and it is an analytical challenge to measure different components of breast milk.

Although the specific protective components within breast milk remain incompletely understood, in The Role of MicroRNAs in NEC, Dr Misty Good of the Children’s Hospital of Pittsburgh described one of the mechanisms by which it is protective against NEC. Dr Good was a member of a team led by Professor David Hackam of Johns Hopkins University School of Medicine that showed how Toll-like receptor 4 (TLR4) could result in increased susceptibility to the disease. Breast milk is protective against NEC by inhibiting TLR4 with the activation of epidermal growth factor (EGFR), which is abundant in breast milk and amniotic fluid.

However, as Dr Sharon Unger of Mount Sinai Hospital in Toronto reiterated in her presentation to SIGNEC in 2015, Donor Human Milk for Very Low Birth Weight Infants, most mothers of very preterm infants are unable to provide a sufficient volume of milk, so supplementation with formula or donor milk is necessary. Dr Unger spoke of the OptiMoM and DoMINO studies and evidence of NEC protection, but concluded that more research is needed into optimizing mother’s own milk, donor milk and fortifiers.

Fortifying the immature gut with probiotics to counteract the negative effects of altered intestinal microflora has been an area of NEC research for some time, and Kate Costeloe, Professor of Paediatrics at Barts and the London Hospitals, has given several presentations to SIGNEC on the Probiotic in Preterm Babies Study (PiPS). In The PiPS Trial, she reported its conclusion that it did not support the routine use of probiotics at the present time as probiotic administration did not show benefit in terms of death or late onset sepsis in the study population. That said, many units in the UK are routinely using probiotics.

At Nationwide Children’s Hospital in Columbus, Ohio, researchers have looked at a probiotic, which Professor Gail E. Besner explained in Novel methods of stem cell therapy and probiotic administration for NEC. Her team discovered that a single dose of Lactobacillus reuteri administered as a biofilm decreases the incidence of NEC and preserves gut barrier function. This is an exciting development, and perhaps the most important question about probiotic use is not ‘yes’ or ‘no’ but which probiotic to use and how best to use it.

It is also critical that we understand the nutritional requirements and capacities of infants that have had NEC. In Nutritional management post Necrotising Enterocolitis: a practical approach, Kate Tavener, Specialist Neonatal Dietitian at King’s College Hospital in London, reported that there is a limited evidence base for feeding post NEC and little consensus on when enteral feeding should restart after medical NEC. Infants who have undergone gut resection may have poorer tolerance to whole protein fat and lactose, and human milk should be the first choice post NEC.