Necrotizing Enterocolitis in Preterm Infants: An Inflammatory Condition at the Crossroads of Intestinal Immaturity, Dysbiosis, and Nutrition

Necrotizing enterocolitis (NEC) remains one of the most devastating gastrointestinal emergencies in neonatology, primarily affecting preterm and low-birthweight infants. Despite advances in neonatal intensive care that have markedly improved survival among these high-risk populations, NEC continues to be associated with significant morbidity and mortality. It is a complex, multifactorial disease that develops at the crossroads of intestinal immaturity, gut microbiota dysbiosis, impaired mucosal immunity, and suboptimal nutritional practices-particularly the use of formula feeding versus breast milk. In high-income countries, the increasing survival of extremely preterm infants has contributed to a higher incidence of NEC. Moreover, low- and middle-income countries, including those in sub-Saharan Africa, must anticipate a similar rise in NEC cases as neonatal care systems evolve and survival rates improve. Proactive strategies are therefore essential to mitigate the burden of this disease. This narrative literature review synthesizes current evidence on NEC pathogenesis, diagnostic approaches, key risk factors, and evidence-based preventive interventions. Emphasis is placed on the role of enteral feeding practices, microbial colonization, and early identification of at-risk neonates. Furthermore, the review explores strategic clinical practices such as the promotion of exclusive breastfeeding, the cautious use of antibiotics, and the potential role of probiotics. Ultimately, reducing NEC incidence and improving outcomes is crucial for lowering neonatal mortality rates globally, particularly in vulnerable preterm populations.