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Am J Clin Nutr. 2017 Sep;106(3):821-830. doi: 10.3945/ajcn.117.152967. Epub 2017 Jun 28.

Nutritional strategies and gut microbiota composition as risk factors for necrotizing enterocolitis in very-preterm infants.

Author information

Department of Neonatal Medicine,
Epidémiologie Clinique, Clinical Investigation Center - Clinical Epidemiology (CIC004), and.
INRA, UMR 1280 Physiology of Nutritional Adaptations, Nantes University Hospital, Nantes, France.
INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center.
Risks in Pregnancy Department, and.
Clinical investigation center CIC P1419, Cochin Hotel-Dieu Hospital, AP-HP, Paris, France.
Micalis Institute, INRA, AgroParisTech, University Paris-Saclay, Paris, France.
EA 4065 Intestinal Ecosystem, Probiotics, Antibiotics, Faculty of Pharmacy, Paris Descartes University, Paris, France.
Department of Neonatal Medicine, Croix Rousse Hospital, Lyon Hospitals, Lyon, France.
Department of Neonatal Medicine, AP-HP, Necker Enfants Malades Hospital, Paris, France; and.
Department of Pediatrics, University of Florida, Gainesville, FL.


Background: The pathophysiology of necrotizing enterocolitis (NEC) remains poorly understood.Objective: We assessed the relation between feeding strategies, intestinal microbiota composition, and the development of NEC.Design: We performed a prospective nationwide population-based study, EPIPAGE 2 (Etude Epidémiologique sur les Petits Ages Gestationnels), including preterm infants born at <32 wk of gestation in France in 2011. From individual characteristics observed during the first week of life, we calculated a propensity score for the risk of NEC (Bell's stage 2 or 3) after day 7 of life. We analyzed the relation between neonatal intensive care unit (NICU) strategies concerning the rate of progression of enteral feeding, the direct-breastfeeding policy, and the onset of NEC using general linear mixed models to account for clustering by the NICU. An ancillary propensity-matched case-control study, EPIFLORE (Etude Epidémiologique de la flore), in 20 of the 64 NICUs, analyzed the intestinal microbiota by culture and 16S ribosomal RNA gene sequencing.Results: Among the 3161 enrolled preterm infants, 106 (3.4%; 95% CI: 2.8%, 4.0%) developed NEC. Individual characteristics were significantly associated with NEC. Slower and intermediate rates of progression of enteral feeding strategies were associated with a higher risk of NEC, with an adjusted OR of 2.3 (95% CI: 1.2, 4.5; P = 0.01) and 2.0 (95% CI: 1.1, 3.5; P = 0.02), respectively. Less favorable and intermediate direct-breastfeeding policies were associated with higher NEC risk as well, with an adjusted OR of 2.5 (95% CI: 1.1, 5.8; P = 0.03) and 2.3 (95% CI: 1.1, 4.8; P = 0.02), respectively. Microbiota analysis performed in 16 cases and 78 controls showed an association between Clostridium neonatale and Staphylococcus aureus with NEC (P = 0.001 and P = 0.002).Conclusions: A slow rate of progression of enteral feeding and a less favorable direct-breastfeeding policy are associated with an increased risk of developing NEC. For a given level of risk assessed by propensity score, colonization by C. neonatale and/or S. aureus is significantly associated with NEC. This trial (EPIFLORE study) was registered at as NCT01127698.


breastfeeding; clostridia; necrotizing enterocolitis; preterm infant; speed of increasing enteral nutrition

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