Table 2 Recommendations and Implementation strategies for NEC Prevention

Clinical Recommendations and GRADE

Implementation Strategies

1. Mom’s own milk (MOM) is the preferred first line nutrition for preterm infants (except for in cases where it is contraindicated). If no MOM is available, donor human milk (DHM) is preferred over formula. [High quality, do it]

2. DHM-based fortifier is preferred over bovine based fortifier. Benefits of human milk based fortifiers outweigh the risks. Can be cost-effective for the healthcare system, with greater cost savings likely in higher rate NICUs. Impact of human milk-based fortifier on growth is inconsistent across studies and growth should be monitored carefully [Moderate quality, probably do it]

3. There is documented benefit from using colostrum for oral care to boost immune response and to encourage mothers to sustain milk production. (Low quality, probably do it).

Adopt a hospital-based policy to support breastfeeding and providing human milk.

Provide education by OBs and Neonatologists when preterm delivery is anticipated about the importance of human milk emphasizing immune as well as nutritional benefit.

Reiterate importance of breastmilk for preemies in a parent handbook or pamphlet, translated into commonly spoken languages and written in simple terms.

Support initiation of pumping within 6 h after delivery and offer pumping at the bedside when possible.

Provide lactation specialist support early (<24 h) and consistently through the stay.

Educate staff (e.g. post-partum RNs, NICU RNs, Residents) using diverse training tools.

Use huddles to remind staff about human milk education and goals.

Provide pumps in the hospital and resources to rent pumps at home.

Track initiation of pumping and milk volumes.

Use colostrum for oral care.

Facilitate regular skin to skin care (aka “kangaroo care”).

Offer peer lactation support.

Promote non-nutritive breast feeding when the infant is stable.

Encourage nutritive breast feeding when appropriate and recommend breast before bottle when possible.

Create a breast feeding plan for discharge.

Clinical Recommendations and GRADE

Implementation Strategies

1. Adopt a unit-approved standardized feeding protocol to reduce inter-provider variation. [Moderate quality, do it].

2. A multi-disciplinary team should be involved in creating, implementing and monitoring adherence to the protocol.

Consider “Feeding rounds” as a way to audit and feedback on compliance with the feeding protocol.

Track initiation of feeds.

Track advancement of feeds.

Track fortification of feedings.

Track growth.

Formalize criteria for identifying and managing feeding intolerance.

Tie feeding protocol to competencies and ongoing staff education.

Clinical Recommendations and GRADE

Implementation Strategies

1. Early recognition tools can be beneficial in patient safety efforts. Validated tools have been shown to differentiate between infants who get NEC compared to those who do not. [Very low evidence, probably do it]

Consider risk tool to use at the unit level (e.g. GutCheckNEC, NeoNEEDS or eNEC).

Use a structured communication script (e.g. Situation-Background-Assessment-Recommendation; SBAR method) to communicate when NEC is suspected and to focus assessment.

Educate parents about warning signs of NEC and preventive measures verbally and with printed materials (e.g. pamphlets) written in a way parents can easily understand. Optimal timing for this education is when initiating, advancing, or adding fortification to feeding.

Use medically accurate terminology when communicating with parents (e.g. “necrotizing enterocolitis” vs. “tummy problems”, etc.)

Communicate baby’s risk factors to parents and emphasize why human milk is important to help prevent NEC and that they play an important role in NEC prevention.

Empower parents and nurses to speak up when concerned.

Clinical Recommendations and GRADE

Implementation Strategies

1. Avoid use of H2 blockers within the first 120 days of life (enteral or parenteral) [Moderate quality, don’t do it]

2. Restrict empiric antibiotic use to 4 days or less for infants without positive blood cultures or clinical suspicion of infection [Moderate quality, don’t do it]

Specify, adopt and automate prescribing guidelines for antibiotics that require a specific number of doses to be ordered.

Adopt electronic alerts that warn the clinician that an H2 blocker is ordered and that it increases the risk for NEC.

Communicate at handoffs about the date and time antibiotics should be stopped.

Collaborate with pharmacists and integrate electronic alerts into electronic health record to remind clinicians to stop unnecessary antibiotics.

Educate hospital personnel (e.g. neonatology, nursing, physician trainees) on recently published guidelines.

Participate in antibiotic stewardship and regional collaborative organizations in multidisciplinary teams.

Evaluate change by measuring the adherence to protocol and the number and % of infants who received prolonged antibiotics or H2 blockers.

Create and share a report on findings within the local NICU.

Give feedback to clinicians on their adherence to the medication stewardship guidelines in a way that is timely, individualized, not punitive, and customizable.