The role of xanthan gum in necrotizing enterocolitis: clinical implications and safety for preterm neonates

Necrotizing enterocolitis (NEC) is severe inflammatory disease that predominantly affects preterm infants and is closely related to shaping the gut microenvironment and immune system. Early-life feeding plays a critical role in the pathophysiology of NEC. Xanthan gum (XG) has viscosity-stabilizing properties and resistance to breast milk amylase. Therefore, XG has therefore been used in the management of dysphagia in infants. However, its safety in the intestines of premature infants remains controversial. This study aims to review current scientific evidence on the use of XG in NEC and to evaluate potential pathophysiological mechanisms from a clinical perspective. Current data suggest that fermentation of XG by the colonic microbiota into short-chain fatty acids may contribute to mucosal injury in the immature gut, although a causal relationship has not been established. Clinical studies show that NEC cases associated with XG-based thickeners have a later onset than classical NEC, with approximately half of cases developing post-discharge. Therefore, regulatory authorities such as the FDA, EFSA, and JECFA have published restrictive guidelines on the use of XG in neonates. In this context, it is crucial that XG-based products be carefully evaluated, especially in at-risk infants, and that the decision to thicken the product be made through a multidisciplinary, individualized approach that considers the infant’s intestinal maturity.