Development of necrotizing enterocolitis in premature infants receiving thickened feeds using SimplyThick®

Abstract

SimplyThick s (ST) has been safely used as a thickener to treat adults who have dysphagia, but the safety of this product has not been studied in premature infants. Xanthan gum is the ingredient in ST that results in thickening and also is an effective laxative. We recently began using ST to treat premature infants with dysphagia and/or gastroesophageal reflux. We describe three cases of premature infants who developed necrotizing enterocolitis (NEC) after they were fed ST. Unlike classic NEC, all three cases presented with late-onset colonic NEC.

Deregulation of intestinal anti-microbial defense by the dietary additive, maltodextrin

“…27 Further evidence in humans demonstrates the pathogenic potential for these dietary additives when combined with other risk factors, as supplementation of infant formula with a xanthan gum-based thickener induced late-onset necrotizing enterocolitis in premature infants. 28,29 Emulsifiers act directly on the mucosal barrier to decrease viscosity, permitting bacterial translocation and potentially driving inflammation. 30 This is observed in the detergent-based dextran sulfate sodium (DSS) colitis model, where bacteria translocate the mucin layer soon after DSS consumption, preceding visible intestinal damage.…”

Feed thickeners and NEC: too risky to chance

“…NEC has now been reported in association with several different thickening agents, including pectin and cellulose, 7 carob-bean gum 3 and xanthan gum. 1 A causative association is biologically plausible, as previously discussed. 1,3 Consequently, we believe that there is presently little justification for the use or recommendation of any feed-thickening agent in infants who were born preterm until reassuring safety data become available in this population.…”

“…We thank Dr Woods et al 1 for reporting three ex-preterm infants who developed late-onset necrotizing enterocolitis (NEC) within a short period of being commenced on a xanthan gum-derived feed thickener. We note that as of May 2011 when the FDA warned against the use of SimplyThick in infants who had been born prematurely, 15 cases of NEC (including two deaths) had occurred in preterm infants who had been fed SimplyThick with their milk.…”

Response to ‘Clarke and Robinson’

“…NEC has now been reported in association with several different thickening agents, including pectin and cellulose, 7 carob-bean gum 3 and xanthan gum. 1 A causative association is biologically plausible, as previously discussed. 1,3 Consequently, we believe that there is presently little justification for the use or recommendation of any feed-thickening agent in infants who were born preterm until reassuring safety data become available in this population.…”