NEC Awareness Day: Preventing Necrotizing Enterocolitis Is an Ongoing Endeavor

May 17, 2021 | by MEDNAX
NEC Awareness Day: Preventing Necrotizing Enterocolitis Is an Ongoing Endeavor

Up to three out of every 1,000 babies born in the United States develop necrotizing enterocolitis (NEC). While the exact etiology of the disease isn’t completely understood, there are several ways to reduce the risk of developing the condition—and Mednax is making huge strides in reducing the risk.

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NEC is one of the most common gastrointestinal emergencies in newborns. It’s most prevalent in infants who are less than 32 weeks gestation at birth and weigh less than 1,500 grams (about 3 pounds). The more premature an infant is born, the higher the risk of acquiring NEC. Smaller babies have a higher risk, but larger, older babies have a higher chance of dying from the disease. 

Often, babies are stable prior to developing NEC, explains Robert Ursprung, M.D., MMSc, Mednax’s director of HRO/patient safety for neonatology and a neonatologist at Cook Children’s Medical Center in Fort Worth, Texas. A baby can have stable vital signs and be tolerating feeds well, then suddenly will have blood in the stool, abdominal distention, and be critically ill. NEC results from some combination of infection, inflammation, and/or lack of appropriate blood flow to the intestines.

“There is something about the immaturity of intestinal cells at that stage of development that creates the conditions that result in NEC,” explains Dr. Ursprung.

In some cases, a portion of the bowel dies, requiring surgical resection. In its most severe forms, infants can develop short bowel syndrome or die.

Preventing NEC takes a multi-pronged approach

“Preventing NEC is a challenge because you have to come at it from multiple angles,” explained Dan Ellsbury, M.D., Mednax’s national director of neonatology quality & safety and a neonatologist at MercyOne Children’s Hospital in Des Moines, Iowa. “It requires increasing the use of breast milk, providing access to donor milk if necessary, reducing exposure to antibiotics and reducing the use of acid-blocking drugs in infants.”

A Focus on Breastfeeding: Once a baby is born preterm, every possible effort must be made to provide breast milk. Often, when babies are born early, their mothers may not produce breast milk yet. And if they do, it likely needs to be fortified because milk from women who deliver prematurely lacks several essential minerals.

“It’s very hard emotionally on the moms,” said Dr. Ursprung. “They are tired and worried because their babies are so tiny, and then we’re asking them to pump every three hours. But mother’s milk is the most important medication we can give premature babies.”

To facilitate breastfeeding, new moms are connected with lactation consultants and provided with free breast pumps. Clinicians also help moms develop a feeding strategy to encourage babies to eat consistently.

Supplementing with Donor Milk: If a mom can’t breastfeed or can’t produce enough milk, donated milk is a second line of defense. Through its partnership with the Human Milk Banking Association of North America, Mednax helps new moms get donor milk to feed their babies. 

Minimizing Antibiotic Usage: Babies have fragile immune systems, but every time they are given antibiotics, the bacteria in the intestinal tract—called the microbiome—is altered, increasing the risk of developing NEC. Through its antibiotic stewardship program, Mednax and its clinicians are committed to thoughtfully restricting the duration and type of antibiotic exposure.

Reducing Antacid Drug Usage: Previously, babies were commonly treated with antacid medications to assist with feeding and reflux concerns.  Studies of these medications have shown minimal benefits for most premature babies and an association with the development of necrotizing enterocolitis. Mednax clinicians have changed their clinical practice to minimize the use of antacid medications in infants.

100,000 Babies and beyond

In 2007, Mednax unveiled 100,000 Babies, an ambitious quality improvement initiative designed to improve the care provided in neonatal intensive care units (NICUs) across the country. By 2013, not only did more babies survive, they survived with fewer complications and spent less time in the NICU. In fact, cases of NEC in Mednax-staffed facilities decreased by 41%.

“The 100,000 Babies campaign sparked significant changes in how our clinicians practice,” Dr. Ellsbury explained. “It was a major driver in changing behavior that continues today.”

More specifically, since 2007, breast milk use in Mednax-staffed facilities rose from 50 to 70% overall and 80% during the first week of life. Similar gains were seen in other areas: antibiotic use with negative blood cultures decreased by 20%, while the use of acid blockers decreased from 17% to 7% in Mednax-staffed NICUs. A 2019 analysis of NEC rates in Mednax-staffed facilities showed 2,489 fewer babies developed NEC than were expected, based on projections from 2007 NEC rates. 

To continue the momentum, Mednax neonatologists hold quality meetings, where clinicians around the country share best practices and strategize on how to continue to reduce the incidence of NEC. Additionally, clinical leaders sift through the thousands of pages of medical research published each year to curate the best evidence-based studies to inform clinical care. 

“What you do as a team at the bedside matters,” Dr. Ursprung said. “It truly contributes to health, but don’t forget that it can also contribute to harm. We need to continue to support mothers during a stressful time and optimize the use of medicine by balancing the risks with the benefits.”

Dr. Ellsbury agrees: “One of the biggest difficulties in quality improvement is that once you have some success, it’s easy to relax and lose the progress that you’ve made. Stay vigilant.”

For more information about our quality improvement efforts, visit the Mednax Center for Research, Education, Quality and Safety (CREQS).