This article conceptualizes necrotizing enterocolitis (NEC) as a chronic condition with lifelong gastrointestinal, neurodevelopmental, and psychosocial sequelae. Current fragmented health care systems inadequately serve NEC survivors and their families after Neonatal Intensive Care Unit (NICU) discharge. Drawing on conceptual frameworks in life course development, chronic disease management, and care coordination for children with medical complexity, we propose an adaptive, tiered framework for post-discharge collaborative care. Three tiers, Standard Enhanced Follow-up, Moderate Complexity Coordination, and Intensive Multidisciplinary Co-Management, align care intensity with patient complexity and include criteria for escalation and de-escalation. This approach emphasizes structured NICU-to-primary care transitions, subspecialty integration, and family-centered coordination.

The policy landscape influences both the delivery of health care and patient outcomes. Governmental funding priorities, legislation and regulation impact aspects of neonatal intensive care, which subsequently affect rates of NEC. We review state policies, including Medicaid coverage of pasteurized human donor milk and pending federal legislation such as the reintroduction of the 2019 Access to Donor Milk Act, which aim to reduce disparities in access. We also review federal appropriations, regulations and other measures, which may directly or indirectly, influence NEC rates. Together, these measures demonstrate how neonatologists can foster a policy environment that mitigates NEC through advocacy.

Establishing a definition for necrotizing enterocolitis has been a goal for the past 50 or more years. Many definitions and diagnostic criteria have been proposed, including the commonly used Bell staging. There are notable similarities and differences between published criteria, but uncertainty as to which criteria are the most important in establishing the initial diagnosis of NEC and assessing progression. In this article, we highlight current approaches to the diagnosis of NEC, summarize features across various published criteria, and discuss approaches that may improve the diagnosis of NEC.

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease primarily affecting preterm infants and is associated with a high mortality and long-term morbidity. Despite decades of research, NEC pathogenesis remains incompletely understood, and early diagnosis is challenging. NEC is a multifactorial disease arising from a complex interplay of factors, including impaired intestinal barrier function, dysregulated immune response, microbial dysbiosis, and a range of antenatal, perinatal, and postnatal exposures. Diagnosis primarily relies on clinical assessment and radiography. This article reviews emerging tools that aim to detect NEC earlier and more accurately.

Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in preterm infants and is a leading cause of morbidity and mortality in this population. Although NEC is localized to the bowel, there are serious associated systemic complications with significant morbidity and mortality. Historically, the diagnostic standard has been plain abdominal radiography. However, the availability of abdominal ultrasound has been emerging as a complementary diagnostic tool allowing for direct visualization of the bowel and abdominal cavity. This article reviews the roles of both modalities with particular emphasis on the complementary role of utilizing, standardizing, and integrating ultrasound for NEC diagnosis.

Necrotizing enterocolitis (NEC) remains one of the most devastating diseases affecting preterm infants, with high mortality and significant long-term morbidity among survivors. Earlier trials have demonstrated broadly comparable outcomes between drainage and laparotomy overall, although recent evidence suggests a high probability of benefit of laparotomy for infants with NEC. Novel therapies, including pentoxifylline, therapeutic hypothermia, remote ischemic conditioning and regenerative biologics, show promise but remain in the early stages of clinical evaluation. Future progress will depend on international collaboration, improved disease stratification and the successful delivery of adequately powered multicenter trials capable of establishing evidence-based treatments for NEC.

The primary focus in advancing necrotizing enterocolitis (NEC) has been on prevention as there have not been major breakthroughs in novel biomarkers or therapeutics, likely due to the multiple etiologies that lead to NEC and its rapidity of onset. Many opportunities to prevent NEC exist in tested standardization of practices based on varying strengths of medical evidence. Learning methods of scaling and spreading these approaches require a sound foundational knowledge of the principles of expanding successful improvement work. This paper provides a primer on these principles, and how they may be applied to reducing NEC in your own clinical context.

Necrotizing enterocolitis (NEC) is a deadly intestinal disease that most commonly occurs in premature infants. Current treatments are reactive rather than preventative, and include feeding cessation, antibiotics, gastric decompression, and supportive care. In severe NEC, surgical intervention is required for intestinal perforation or failure of medical management. Promising treatment modalities are being explored to prevent NEC and reduce NEC severity, including probiotics, probiotic delivery systems, growth factors, stem cell and small molecule therapeutics, human milk oligosaccharides, and hydrogen sulfide derivatives. These advancements show great potential to prevent and/or treat NEC, as well as reduce long-term complications in NEC survivors.

Necrotizing enterocolitis is a devastating complication of prematurity with high mortality and lifelong morbidities. The burden of disease is inequitably distributed, with higher incidence and mortality in racialized, socioeconomically disadvantaged, and geographically marginalized populations. These disparities reflect structural inequities in maternal health, preterm birth risk, quality of care, and access to protective interventions such as mother's own milk and donor human milk. Reducing necrotizing enterocolitis disparities requires multilevel solutions spanning health policy, equitable perinatal regionalization, investment in underresourced hospitals, and evidence-based neonatal care. Improving access to mother's own milk and pasteurized donor human milk are potentially the highest yield interventions.

The practical considerations for using pasteurized donor human milk (PDHM) require a standardized yet individualized approach. Mother's own milk should be prioritized with PDHM serving as a bridge. Neonatal intensive care unit should focus on early feeding and a base diet of human milk MOM supplemented with PDHM. Human milk is critical to reducing necrotizing enterocolitis risk in very preterm infants. Given variability in PDHM composition, strategic fortification is necessary to optimize growth. Reliable milk handling, staff and family education, and shared decision-making with parents are essential. Collaboration with milk banks and promotion of donation are key to ensuring access and sustainability.

Necrotizing enterocolitis (NEC) is a devastating neonatal intestinal disease driven by complex interactions between prematurity, microbial dysbiosis, immune dysregulation, and impaired intestinal barrier function. This article highlights recent advances in NEC pathogenesis, focusing on the role of toll-like receptor 4-mediated inflammatory signaling and the contribution of maternal inflammation and chorioamnionitis to disease susceptibility. Transcriptomic and spatial profiling studies further demonstrate that classical NEC and cardiac NEC possess distinct molecular signatures and identify diverse inflammatory endotypes within classical NEC. These findings support a precision medicine approach to NEC prevention and treatment.

Necrotizing enterocolitis (NEC) is a serious, sometimes fatal complication of prematurity and a challenging diagnosis to discuss with parents. In this article, we will discuss communication topics and strategies before, during and after a diagnosis of NEC, including the protective role of mother's own milk, the inability to fully eliminate the risk of NEC, the possibility of fulminant NEC, and long-term sequelae. We argue for clear and transparent communication to partner with and empower families, especially at the time of NEC diagnosis and at key transitions of care throughout the neonatal intensive care unit stay and beyond.

A diagnosis of necrotizing enterocolitis (NEC) often affects families for a lifetime. Given the profound burden of NEC, families are uniquely positioned to harness the power of their experience to advocate for and contribute to research. Clinicians and scientists can also collaborate with families affected by NEC to improve care as well as prevention and treatment strategies. Elevating the voices of patient-families affected by NEC can help advance the field by helping identify meaningful gaps in science, conveying the urgency of improving outcomes, and providing knowledge only known by families carrying the lifelong devastation of NEC.