Regenerative Cell and Cell-Free Therapies for Necrotizing Enterocolitis: Progress Toward Clinical Translation

OBJECTIVE: Necrotizing enterocolitis (NEC) remains one of the most devastating gastrointestinal diseases of prematurity, carrying high mortality and long-term morbidity with no targeted disease-modifying therapy currently available. This review synthesizes preclinical and translational evidence for stem cell- and extracellular vesicle (EV)-based regenerative therapies in NEC and identifies the critical steps required for clinical translation. STUDY DESIGN: A narrative review of preclinical studies, systematic reviews, meta analyses, and early-phase clinical trial data evaluating stem cell-based and cell free EV therapies for NEC was performed. Evidence was organized across cell populations, mesenchymal stem cells (MSCs), amniotic fluid stem cells (AFSCs), placental-derived stem cells, and neural stem cells, and their derived EVs and considerations. regeneration, barrier exosomes, with synthesis of mechanistic, translational, safety, and ethical Results: Multiple stem cell types consistently reduce NEC incidence, severity, and mortality in experimental models. Protective effects are mediated through epithelial reinforcement, Wnt/β-catenin pathway activation, immunomodulation, and angiogenesis. Cell-free strategies using MSC- and AFSC derived EVs reproduce comparable benefits with a more favorable manufacturing and safety profile. Early-phase clinical trials of MSCs in other neonatal conditions confirm short-term tolerability, though no NEC-specific stem cell or EV trial has been completed. CONCLUSION: Regenerative cell and cell-free therapies represent a compelling disease-modifying strategy for NEC. Advancing this field requires standardized cell and EV characterization, optimized dosing and delivery protocols, large-animal model validation, and rigorously designed early-phase clinical trials with careful attention to safety, ethics, and regulatory frameworks.