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

Pediatrics. 2016 May;137(5):e20151119. doi: 10.1542/peds.2015-1119.


Objective: To reduce the incidence of necrotizing enterocolitis (NEC) among very low birth weight (VLBW) infants admitted to 8 intensive care nurseries from a 2010 baseline of 8.0% to <4.0% by 2012 and sustain for 6 months using quality improvement (QI) methodology.

Methods: A multidisciplinary NEC QI team used the Vermont Oxford Network definition of NEC and the Institute for Healthcare Improvement model. The specific aims were evidenced based and included (1) standardized early human milk feedings, (2) conservative feeding guidelines during blood transfusions and indomethacin treatment, and (3) restriction of ranitidine use in VLBW infants. Inclusion criteria included VLBW infants admitted within the study period without NEC. Exclusion criteria included established NEC or spontaneous intestinal perforation unrelated to NEC. The incidence of NEC and NEC-related surgery were tracked using statistical process control methodology.

Results: The baseline NEC rate in 2010 was 8% (27 NEC cases in 335 VLBW infants). After initiation of early human-milk feeding and conservative feeds during blood transfusions guidelines in November 2011, only 3.1% (19 of 606 VLBW infants) had developed NEC through December 2013 (P = .001). Special cause variation was noted in June 2012 establishing a new centerline at 3.1%. NEC-related mortality decreased from a 2010 baseline mean of 2.7% to a new baseline mean of 0.9% from January 2011 to December 2013.

Conclusions: Implementation of QI initiatives decreased the NEC rate from 8.0% to <4.0%. Early human milk feedings and conservative feeding during blood transfusion policies appear to have significant impact on NEC reduction.

MeSH terms

  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Blood Transfusion
  • Enterocolitis, Necrotizing / epidemiology
  • Enterocolitis, Necrotizing / mortality
  • Enterocolitis, Necrotizing / prevention & control*
  • Humans
  • Incidence
  • Indomethacin / therapeutic use
  • Infant, Newborn
  • Infant, Premature
  • Infant, Premature, Diseases / epidemiology
  • Infant, Premature, Diseases / mortality
  • Infant, Premature, Diseases / prevention & control*
  • Infant, Very Low Birth Weight*
  • Milk, Human*
  • Practice Guidelines as Topic
  • Quality Improvement*
  • Ranitidine / therapeutic use


  • Anti-Inflammatory Agents, Non-Steroidal
  • Ranitidine
  • Indomethacin