The e-Journal of Neonatology Research

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NEC Reduction Opinions

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Neonatal Caregiver’s Opinions Regarding NEC as a Zero Tolerance Quality Outcome

Jonathan R. Swanson MD1, Phillip V. Gordon MD, PhD2, and Susan Orlando DNS APRN NNP-BC CNS3

1Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
2Department of Pediatrics, Tulane School of Medicine, New Orleans, LA
3Louisiana State University Health Sciences Center, School of Nursing, New Orleans, LA

Address correspondence:

Jonathan Swanson, MD
Department of Pediatrics
Box 800386
University of Virginia
Charlottesville, VA 22908

Author Disclosure: The authors have nothing to disclose.


Background: We sought to poll neonatal nurse practitioners (NNPs) and neonatologists nationwide using an online survey mechanism regarding their opinion toward necrotizing enterocolitis as a zero tolerance outcome (versus that of using national averages as the measure of expectation).

Methods: A waiver was granted to the e-Journal of Neonatology Research by Tulane School of Medicine’s Internal Review Board for professional opinion surveys using a standardized format. An on-line survey was created to sample both respondent opinions as well as their reported patterns with regard to aspects of practice thought to be relevant to NEC risk. The survey was administered as an open access link through the e-Journal of Neonatology Research, Winter Issue, 2012. The survey data collection was terminated after 12 weeks.

Results: Forty eight respondents participated in the survey.  One half of respondents reported agreement with a zero tolerance approach and half did not. Most respondents reported agreement with mothers’ milk promotion, early feeding, minimizing antibiotic exposure and removal of central lines as soon as possible. Less than half of respondents agreed with glycerin use PRN, making infants NPO during blood transfusions, use of antibiotics during viral episodes, and surveillance for cow’s milk intolerance. Three fourths of respondents reported that their practices did not have comprehensive quality improvement initiatives for NEC prevention whereas two thirds reported that their practices did use the specific NEC reduction practices which they endorsed in the previous part of the survey.

Conclusions: There is tremendous disparity of opinion and reported practice with regard to NEC prevention among the 48 respondents of this survey. Further research of NEC quality improvement practices may help clinicians determine how best to proceed with this important component of their practice.

Key Words: necrotizing enterocolitis, opinion survey, quality improvement


A quality improvement manuscript was recently published in the e-Journal of Neonatology Research (eJNR).1 It suggested that a comprehensive quality improvement approach to necrotizing enterocolitis (NEC) with a zero tolerance outcome goal might be superior to that of conventional wisdom, where leaders and quality improvement directors match their outcomes against national averages or utilize shrunken estimates to determine if their year to year variance represent true trend of noise. During the same edition, eJNR published an online survey, enquiring whether or not its readership thought zero tolerance was a reasonable policy. This manuscript summarizes the findings of that survey.


We received a three-year waiver from the Tulane Institutional Review Board for online professional opinion surveys using Polldaddy™ technology to create anonymous survey questions in a standardized format linked to the e-Journal of Neonatology Research. The table of contents for the issue linked to the survey was sent to more than 5000 recipients throughout the continental United States, divided into four batches over the course of four days, with each containing a direct link to the study survey entitled “What do Neonatal Care Givers think about NEC as a zero tolerance outcome” and can be found at:  These surveys are limited to a few questions, with the intent that brevity might encourage voluntary participation. The survey was designed such that respondents would first state their opinion about zero tolerance, then choose the clinical practices that they think reduce NEC, then confirm whether or not their clinical practice employs the practices they endorse and whether or not they think their approach is comprehensive with regard to NEC (i.e. the survey forces the respondent to evaluate whether or not their practice is realistically trying to achieve zero tolerance). The survey was set up such that participants could not take the survey twice from the same computer (via cookie technology), thereby discouraging repeated taking of the survey. The survey instructions also explicitly prohibited repeated taking of the survey.


Data was analyzed by extracting raw data within each question, then comparing the ratios of positive to negative choices. Also, when questions overlapped in content, answer ratios were evaluated for congruence by simple Boolean logic. The validity of the sample size was evaluated relative to the known size of the work force as a percentage of the total.


Do you think that it is realistic to approach NEC as a zero tolerance outcome in quality improvement initiatives?

This was the central question and theme of this survey. Respondents were equally divided in the answers (24 said yes, 24 said no).

Which of the following interventions reduce the incidence of NEC (choose all that apply)?

We found a wide disparity of responses in the nine possible answers that the respondents were allowed to choose (Figure 1). The majority of respondents agreed with mother’s milk, early feeding, minimizing antibiotic exposure and getting central lines out as soon as possible. In contrast, only three respondents agreed with protocols for giving antibiotics during symptomatic illness from viral infection to prevent bacterial translocation across the intestinal mucosa. Regarding NEC associated with blood transfusion, approximately 40% of respondents thought the minimizing blood draws and holding feeds during transfusions were appropriate. Likewise, guidelines for routine surveillance for cow’s milk intolerance and use of glycerin for failure to stool were endorsed by 25-29 percent.

Does your NICU employ some version of each of the clinical guidelines that you endorsed in the questions above?

Sixty four percent of respondents said yes, thirty six percent of respondents said no.

Based upon the above answers, does your NICU have a comprehensive strategy for NEC prevention?

Twenty-eight percent of respondents said yes, seventy-two percent of respondents said no.


Forty eight neonatal care givers responded to this survey, making it a pilot survey of opinion. We found that respondents are split down the middle with regard to whether or not a zero tolerance approach to NEC is realistic. In contrast, the vast majority of respondents incorporate multiple interventions that are applicable to NEC prevention (including mothers’ milk promotion, early feeding, minimizing antibiotic exposure and getting central lines out early). In other words, most neonatologists report practicing multiple intervention approaches. It may be just a question of how many interventions are required to be considered comprehensive. Forty percent of neonatologists also endorse strategies that may help minimize transfusion related NEC. Fewer are believers in relief of physiologic constipation, surveillance for cow’s milk intolerance and prophylactic protection of viremic babies from bacterial translocation. All of these interventions were utilized in the institution that suggested NEC should be a zero tolerance outcome.1

The most concerning finding may be that three quarters of respondent report that their NICU does not have a comprehensive strategy for NEC prevention. In other words, the things they are employing happen to be good for NEC prevention, but were not initiated as part of a comprehensive strategy. Whether they believe in zero tolerance or not, NEC prevention should be an important priority for every NICU and a comprehensive quality improvement approach to NEC should be a goal of every quality improvement director.


Based on this survey, most respondents practice multiple interventions that are thought to help prevent NEC but most of the NICUs they practice in do not have active comprehensive approaches for NEC prevention. This likely represents an important opportunity for national quality improvement.


  1. Benjamin J, Chong E, Reynolds J, Gordon PV. Detailed analysis of NEC risks across a decade in a low incidence NICU: can we drive the incidence of NEC toward zero? e-J Neonatal Res 2012; 2(4): 181-9.

PII: eJNR21606072v3i3p6y2013

Written by Dr Phillip Gordon

February 13th, 2013 at 5:00 am

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