Preventive strategies and factors associated with surgically treated necrotising enterocolitis in extremely preterm infants: an international unit survey linked with retrospective cohort data analysis

BMJ Open. 2019 Oct 14;9(10):e031086. doi: 10.1136/bmjopen-2019-031086.


Objectives: To compare necrotising enterocolitis (NEC) prevention practices and NEC associated factors between units from eight countries of the International Network for Evaluation of Outcomes of Neonates, and to assess their association with surgical NEC rates.

Design: Prospective unit-level survey combined with retrospective cohort study.

Setting: Neonatal intensive care units in Australia/New Zealand, Canada, Finland, Israel, Spain, Sweden, Switzerland and Tuscany (Italy).

Patients: Extremely preterm infants born between 240 to 286 weeks' gestation, with birth weights<1500 g, and admitted between 2014-2015.

Exposures: NEC prevention practices (probiotics, feeding, donor milk) using responses of an on-line pre-piloted questionnaire containing 10 questions and factors associated with NEC in literature (antenatal steroids, c-section, indomethacin treated patent ductus arteriosus and sepsis) using cohort data.

Outcome measures: Surgical NEC rates and death following NEC using cohort data.

Results: The survey response rate was 91% (153 units). Both probiotic provision and donor milk availability varied between 0%-100% among networks whereas feeding initiation and advancement rates were similar in most networks. The 9792 infants included in the cohort study to link survey results and cohort outcomes, revealed similar baseline characteristics but considerable differences in factors associated with NEC between networks. 397 (4.1%) neonates underwent NEC surgery, ranging from 2.4%-8.4% between networks. Standardised ratios for surgical NEC were lower for Australia/New Zealand, higher for Spain, and comparable for the remaining six networks.

Conclusions: The variation in implementation of NEC prevention practices and in factors associated with NEC in literature could not be associated with the variation in surgical NEC incidence. This corroborates the current lack of consensus surrounding the use of preventive strategies for NEC and emphasises the need for research.

Keywords: neonatology; paediatric gastroenterology; paediatrics; perinatology.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cause of Death*
  • Cohort Studies
  • Data Analysis
  • Databases, Factual
  • Enterocolitis, Necrotizing / mortality
  • Enterocolitis, Necrotizing / prevention & control*
  • Enterocolitis, Necrotizing / surgery*
  • Female
  • Hospital Mortality / trends
  • Humans
  • Infant, Extremely Premature*
  • Infant, Newborn
  • Infant, Premature, Diseases / diagnosis
  • Infant, Premature, Diseases / mortality
  • Infant, Premature, Diseases / surgery*
  • Intensive Care Units, Neonatal
  • Internationality
  • Male
  • Primary Prevention / methods
  • Probiotics / administration & dosage*
  • Prognosis
  • Retrospective Studies
  • Risk Factors
  • Surveys and Questionnaires
  • Survival Analysis
  • Treatment Outcome