Necrotising enterocolitis (NEC) is a serious, life-threatening disease in preterm
infants. Preterm birth, affecting over 52,000 babies per year (around 7.3% of live
births), is the largest cause of neonatal mortality in the UK. The 2019 NHS Long Term
Plan aims to reduce neonatal mortality by 50% with plans to "improve the safety and
effectiveness of neonatal critical care" and "enhance the experiences of families" during
this worrying period.
An estimated 12% of infants born weighing <1500g develop NEC and 30% of these die.
Survivors have an increased risk of adverse neurodevelopmental outcomes, including
cerebral palsy and cognitive impairment. In the UK, NEC rates are collected by the
National Neonatal Audit Programme (NNAP), a national audit run by the Royal College of
Paediatrics and Child Health, commissioned by the Healthcare Quality Improvement
Partnership (https://nnap.rcpch.ac.uk).
The East Midlands Neonatal Operational Delivery Network (EMNODN)
(https://www.emnodn.nhs.uk) is one of 11 clinically managed Neonatal Operational Delivery
Networks in England. ODNs were formed, in 2003, by the Department of Health, to ensure
that babies and their families receive high quality, equitable and accessible care. The
rate of NEC in the EMNODN has remained above the national average since 2017 (when this
measure was added to NNAP) and there are wide variations between units.
Preterm infants are unable to directly suckle on the breast. Mothers express breastmilk
which is fed to their infant via an oro/nasogastric tube. As infants grow and mature,
they develop the ability to suck and swallow and establish breastfeeding. Some infants
continue to receive own mother's milk via a cup, syringe, or bottle as per parental
choice; all these are included within 'own mother's milk feeding'. Encouraging and
supporting own mother's milk feeding prevents NEC and has several additional advantages,
including improved long-term neurodevelopment and parent-infant bonding. Health economic
analysis estimates that if all premature infants were fed own mother's milk, the total
lifetime cost saving to the NHS would be £46.7 million (£30.1 million in the first year
of life) and there would be 238 fewer deaths per year with a gain of £153.4 million in
lifetime productivity. The adjusted incremental costs of medical NEC and surgical NEC
over and above the average costs incurred for extremely premature infants without NEC, in
2011, were estimated to be $74,004 (95% confidence interval (CI), $47,051-$100,957) and
$198,040 (95% CI, $159,261-$236,819) per infant, respectively.
Early start and continuation of feeding with own mother's milk, such that babies go home
breastfeeding, is vital to ensure babies continue to receive own mother's milk throughout
neonatal care and remain at a reduced risk of NEC. Unfortunately, in NNAP, rates of any
breast milk feeding at discharge in EMNODN have been consistently below the national
average, again with wide local variations.
National recommendations cite a need for quality improvement (QI) efforts to boost own
mother's milk feeding to reduce NEC. In 2020, NNAP recommended that "if rates of NEC are
relatively high, seek to identify and implement potentially better practices" and to
"focus on the early initiation and sustainment of breastmilk feeding in conjunction with
parents by reviewing data and processes" and "undertake selected QI activities suited to
the local context". In keeping with this, the EMNODN has created a NEC Care Bundle which
was introduced it to the 11 neonatal units in September 2022, with use fully embedded by
December 2022.
Care bundles are a group of evidence-based interventions related to a disease or care
process that, when executed together, result in better outcomes than when implemented
individually. Interventions should be evidence-based, accepted as best practice, simple
to implement, and part of day-to-day practice. This care bundle consists of
recommendations, and parent-facing information, created by a multi-disciplinary team. It
contains recommendations in two main areas: promotion of own mother's milk feeding and
optimising nutritional care of preterm infants by ensuring early and adequate parenteral
nutrition, given when infants cannot have sufficient milk feeds such as in the first
hours after birth, while building milk feeds and when unwell, oropharyngeal colostrum
(practice of giving own mothers' first milk directly into the infant's oropharynx to
enhance immunity and protect against NEC), optimal time and speed of increasing milk
feeds, and use of other interventions such as human donor milk, probiotics and breast
milk fortifiers.
There is some evidence that QI programmes using care bundles can improve rates of own
mother's milk feeding in neonatal units. A study in the East of England showed that
introduction of a care bundle increased the prevalence of own mother's milk feeding from
50 to 57%. While such previous studies have looked at some measures of effectiveness of
implementation, none have explored the effect of complex interventions on NEC rates and
other feeding practices.