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Feng B, Zhang Z, Wei Q, Mo Y, Luo M, Jing L, Li Y. A prediction model for neonatal necrotizing enterocolitis in preterm and very low birth weight infants. Front Pediatr 2023; 11:1242978. [PMID: 37920794 PMCID: PMC10619757 DOI: 10.3389/fped.2023.1242978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 11/04/2023] Open
Abstract
Objectives Neonatal necrotizing enterocolitis (NEC) is a severe gastrointestinal disease that primarily affects preterm and very low birth weight infants, with high morbidity and mortality. We aim to build a reliable prediction model to predict the risk of NEC in preterm and very low birth weight infants. Methods We conducted a retrospective analysis of medical data from infants (gestational age <32 weeks, birth weight <1,500 g) admitted to Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. We collected clinical data, randomly dividing it into an 8:2 ratio for training and testing. Multivariate logistic regression was employed to identify significant predictors for NEC. Principal component analysis was used for dimensionality reduction of numerical variables. The prediction model was constructed through logistic regression, incorporating all relevant variables. Subsequently, we calculated performance evaluation metrics, including Receiver Operating Characteristic (ROC) curves and confusion matrices. Additionally, we conducted model performance comparisons with common machine learning models to establish its superiority. Results A total of 292 infants were included, with 20% (n = 58) randomly selected for external validation. Multivariate logistic regression revealed the significance of four predictors for NEC in preterm and very low birth weight infants: temperature (P = 0.003), Apgar score at 5 min (P = 0.004), formula feeding (P = 0.007), and gestational diabetes mellitus (GDM, P = 0.033). The model achieved an accuracy of 82.46% in the test set with an F1 score of 0.90, outperforming other machine learning models (support vector machine, random forest). Conclusions Our logistic regression model effectively predicts NEC risk in preterm and very low birth weight infants, as confirmed by external validation. Key predictors include temperature, Apgar score at 5 min, formula feeding, and GDM. This study provides a vital tool for NEC risk assessment in this population, potentially improving early interventions and child survival. However, clinical validation and further research are necessary for practical application.
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Affiliation(s)
- Baoying Feng
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Disease, Nanning, China
| | - Zhihui Zhang
- Department of Applied Mathematics, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Qiufen Wei
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Disease, Nanning, China
| | - Yan Mo
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Disease, Nanning, China
| | - Mengmeng Luo
- Department of Biological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Lianfang Jing
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Disease, Nanning, China
| | - Yan Li
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Disease, Nanning, China
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Cheddadi R, Khandekar NN, Yeramilli V, Martin C. The impact of maternal stress on the development of necrotizing enterocolitis: A comprehensive review. Semin Pediatr Surg 2023:151324. [PMID: 37316382 DOI: 10.1016/j.sempedsurg.2023.151324] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Necrotizing Enterocolitis (NEC) is a devastating intestinal inflammatory disease with significant morbidity and mortality. Numerous predictors have been implicated in the development of NEC, with a relatively less emphasis on maternal factors. Pregnancy drives women into a new stage of life that increases their susceptibility to biological and psychological stress. Additionally, maternal stress during pregnancy has been linked to various complications that can negatively impact both the mother and the developing fetus. These detrimental effects are facilitated by various systemic modifications. Similarly, there is evidence from animal studies that suggest a relationship between maternal stress and the occurrence of NEC due to the alterations observed in neonates. In this review, we will (1) discuss the physiological and psychological burden of maternal stress and how it can be linked to NEC, (2) summarize various predictors and risk factors of NEC, and (3) discuss the most widely utilized animal models for assessing the effects of prenatal stress on offspring.
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Affiliation(s)
- Riadh Cheddadi
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States
| | | | - Venkata Yeramilli
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States
| | - Colin Martin
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States.
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Screening inflammatory protein biomarkers on premature infants with necrotizing enterocolitis. Inflamm Res 2023; 72:757-768. [PMID: 36806964 PMCID: PMC10129932 DOI: 10.1007/s00011-023-01702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/19/2023] [Accepted: 02/04/2023] [Indexed: 02/21/2023] Open
Abstract
OBJECTIVE This study aimed to explore potential inflammatory biomarkers for early prediction of necrotizing enterocolitis (NEC) in premature infants. METHODS Plasma samples were collected from premature infants with NEC (n = 30), sepsis (n = 29), and controls without infection (n = 29). The 92 inflammatory-related proteins were assessed via high-throughput OLINK proteomics platform. RESULTS There were 11 inflammatory proteins that significate differences (p < 0.05) among NEC, sepsis and control preterm infants, which include IL-8, TRAIL, IL-24, MMP-10, CCL20, CXCL1, OPG, TSLP, MCP-4, TNFSF14 and LIF. A combination of these 11 proteins could serve as differential diagnosis between NEC and control infants (AUC = 0.972), or between NEC and sepsis infants (AUC = 0.881). Furthermore, the combination of IL-8, OPG, MCP-4, IL-24, LIF and CCL20 could distinguish Stage II and III of NEC (AUC = 0.977). Further analysis showed the combination of IL-8, IL-24 and CCL20 have the best prediction value for NEC and control (AUC = 0.947), NEC and sepsis (AUC = 0.838) and different severity of NEC (AUC = 0.842). CONCLUSION Inflammatory proteins were different expressed in premature infants with NEC compared with controls or sepsis. Combining these proteins provide a higher diagnostic potential for preterm NEC infants.
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Lin H, Xu C, Chen J, Ma X, Shi L, Shi W, Du L, Ni Y. Alteration of the gut microbiota after surgery in preterm infants with necrotizing enterocolitis. Front Pediatr 2023; 11:993759. [PMID: 36793334 PMCID: PMC9923499 DOI: 10.3389/fped.2023.993759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To investigate the dynamic changes in the intestinal microbiota in preterm infants with necrotizing enterocolitis (NEC) before and after treatment via a prospective case-control study. METHODS Preterm infants with NEC and preterm infants with similar age and weight (control group) were enrolled in this study. They were divided into NEC_Onset (diagnosis time), NEC_Refeed (refeed time), NEC_FullEn (full enteral nutrition time), Control_Onset, and Control_FullEn groups according to the time of the fecal material collected. Except for basic clinical information, fecal specimens of the infants were obtained as well at indicated times for 16S rRNA gene sequencing. All infants were followed up after discharge from the NICU, and the growth data of the corrected age of 12 months were acquired from the electronic outpatient system and telephonic interviews. RESULTS A total of 13 infants with NEC and 15 control infants were enrolled. A gut microbiota analysis showed that the Shannon and Simpson indices were lower in the NEC_FullEn group than in the Control_FullEn group (p < .05). Methylobacterium, Clostridium_butyricum, and Acidobacteria were more abundant in infants with NEC during diagnosis. Methylobacterium and Acidobacteria were remained plentiful in the NEC group until the end of treatment. These bacteria species were significantly positively correlated with CRP and negatively correlated with platelet count. The rate of delayed growth was higher in the NEC group than in the control group (25% vs. 7.1%) at 12 months of corrected age, but there was no significant difference. In addition, the pathways of synthesis and degradation of ketone bodies were more active in the NEC subgroups, including both the NEC_Onset group and the NEC_FullEn group. The pathway of sphingolipid metabolism was more active in the Control_FullEn group. CONCLUSION Even after reaching the full enteral nutrition period, alpha diversity in infants with NEC who underwent surgery was lower than that in the control group infants. It may take more time to reestablish the normal gut flora of NEC infants after surgery. The pathways of the synthesis and degradation of ketone bodies and sphingolipid metabolism might be related to the pathogenesis of NEC and physical development after the occurrence of NEC.
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Affiliation(s)
- Huijia Lin
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Cuifang Xu
- Department of National Clinical Research Center, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Junjin Chen
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiaolu Ma
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Liping Shi
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei Shi
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lizhong Du
- Department of NICU, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yan Ni
- Department of National Clinical Research Center, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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鲁 春, 刘 克, 乔 高, 罗 源, 程 慧, 杜 书. Risk factors for necrotizing enterocolitis in preterm infants: a Meta analysis. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:908-916. [PMID: 36036130 PMCID: PMC9425871 DOI: 10.7499/j.issn.1008-8830.2202085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To systematically evaluate the risk factors for necrotizing enterocolitis (NEC) in preterm infants. METHODS PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were searched for case-control studies and cohort studies on the risk factors for NEC in preterm infants published up to December 2021. RevMan 5.3 software was used to perform the Meta analysis. RESULTS A total of 38 studies were included (28 case-control studies and 10 cohort studies). The Meta analysis showed that maternal gestational diabetes (OR=2.96, P<0.001), intrahepatic cholestasis during pregnancy (OR=2.53, P<0.001), preeclampsia (OR=1.73, P=0.020), history of neonatal asphyxia (OR=2.13, P<0.001), low gestational age (OR=1.23, P=0.010), sepsis (OR=5.32, P<0.001), patent ductus arteriosus (OR=1.57, P=0.001), congenital heart disease (OR=3.78, P<0.001), mechanical ventilation (OR=2.23, P=0.020), history of antibiotic use (OR=1.07, P<0.001), use of vasopressors (OR=2.34, P=0.040), and fasting (OR=1.08, P<0.001) were risk factors for NEC in preterm infants, while cesarean section (OR=0.73, P=0.004), use of pulmonary surfactant (OR=0.43, P=0.008), and breastfeeding (OR=0.24, P=0.020) were protective factors against NEC. CONCLUSIONS Maternal gestational diabetes, intrahepatic cholestasis during pregnancy, preeclampsia, low gestational age, fasting, sepsis, patent ductus arteriosus, congenital heart disease, and histories of asphyxia, mechanical ventilation, antibiotic use, and use of vasopressors may increase the risk of NEC in preterm infants, while cesarean section, use of pulmonary surfactant, and breastfeeding may decrease the risk of NEC in preterm infants.
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Affiliation(s)
| | | | | | - 源 罗
- 郑州大学第一附属医院新生儿科, 河南郑州450052
| | - 慧清 程
- 郑州大学第三附属医院新生儿科,河南郑州450052
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Tan X, Zhou Y, Xu L, Zhang L, Wang J, Yang W. The predictors of necrotizing enterocolitis in newborns with low birth weight: A retrospective analysis. Medicine (Baltimore) 2022; 101:e28789. [PMID: 35363166 PMCID: PMC9282129 DOI: 10.1097/md.0000000000028789] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/20/2022] [Indexed: 01/04/2023] Open
Abstract
There are needs to investigate the influencing factors of necrotizing enterocolitis (NEC) in low birth weight (LBW) newborns, to provide insights into the clinical management of NEC.This study was a retrospective cohort study. Infants admitted to our hospital from January 1, 2019 to June 30, 2021 were selected. The clinical characteristics of NEC and no-NEC infants were evaluated. Logistic regression analyses were conducted to assess the risk factors of NEC in LBW infants.A total of 192 LBW infants were included, the incidence of NEC in LBW infants was 35.42%. There were significant differences in the congenital heart disease, sepsis, breastfeeding, blood transfusion and probiotics feeding between NEC and no-NEC group (all P < .05), and there were no significant differences in birth weight, gestational age, mother's pregnancy-induced hypertension, premature rupture of fetal membrane, amniotic fluid pollution, fetal asphyxia, neonatal respiratory distress syndrome and mechanical ventilation between NEC and no-NEC group (all P > .05). Congenital heart disease (OR: 2.128, 95% CI: 1.103-3.511), sepsis (OR: 1.630, 95% CI: 1.022-2.549), and blood transfusion (OR: 1.451, 95% CI: 1.014-2.085) were the independent risk factors for NEC in LBW infants, and breastfeeding (OR: 0.494, 95% CI: 0.023-0.928), probiotics feeding (OR: 0.816, 95% CI: 0.782-0.982) were the protective factors for the NEC in LBW infants. The prognosis of NEC infants undergone surgery treatment was better than that of infants undergone conservative treatments (P = .043).The incidence of NEC in LBW is high, which is affected by many factors, and comprehensive interventions targeted on the risk and protective factors should be made to improve the prognosis of LBW infants.
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Affiliation(s)
- Xuerong Tan
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
- Nursing Department, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Yunxia Zhou
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Lan Xu
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Li Zhang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Jiaying Wang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Wenqiong Yang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
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王 又, 郑 美, 肖 晔, 曲 洋, 武 辉. Risk factors for necrotizing enterocolitis and establishment of prediction model of necrotizing enterocolitis in preterm infants. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:41-48. [PMID: 35177174 PMCID: PMC8802389 DOI: 10.7499/j.issn.1008-8830.2109086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/25/2021] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To investigate the risk factors for necrotizing enterocolitis (NEC) in preterm infants, and to establish a scoring model that can predict the development and guide the prevention of NEC. METHODS A retrospective analysis was performed on the medical data of preterm infants who were admitted to the Department of Neonatology,Bethune First Hospital of Jilin University, from January 2011 to December 2020. These infants were divided into two groups: NEC (298 infants with Bell II stage or above) and non-NEC (300 infants). Univariate and multivariate analyses were performed to identify the factors influencing the development of NEC. A nomogram for predicting the risk of NEC was established based on the factors. The receiver operator characteristic (ROC) curve and the index of concordance (C-index) were used to evaluate the predictive performance of the nomogram. RESULTS The multivariate logistic regression analysis showed that grade ≥2 intracranial hemorrhage, peripherally inserted central catheterization, breast milk fortifier, transfusion of red cell suspension, hematocrit >49.65%, mean corpuscular volume >114.35 fL, and mean platelet volume >10.95 fL were independent risk factors for NEC (P<0.05), while the use of pulmonary surfactant, the use of probiotics, and the platelet distribution width >11.8 fL were protective factors against NEC (P<0.05). The nomogram showed good accuracy in predicting the risk of NEC, with a bootstrap-corrected C-index of 0.844. The nomogram had an optimal cutoff value of 171.02 in predicting the presence or absence of NEC, with a sensitivity of 74.7% and a specificity of 80.5%. CONCLUSIONS The prediction nomogram for the risk of NEC has a certain clinical value in early prediction, targeted prevention, and early intervention of NEC.
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Zvizdic Z, Milisic E, Jonuzi A, Terzic S, Zvizdic D, Vranic S. The Effects of Ranitidine Treatment on the Risk of Necrotizing Enterocolitis in Preterm Infants: A Case-Control Study. ACTA MEDICA (HRADEC KRÁLOVÉ) 2021; 64:8-14. [PMID: 33855953 DOI: 10.14712/18059694.2021.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Gastric acidity plays an important role in the protection of infants against various pathogens from the environment. The histamine-2 receptor blockers (H2-blockers) are off-labeled drugs that are frequently prescribed in preterm neonates to prevent stress ulcers. The impact of the H2-blockers on the development of the necrotizing enterocolitis (NEC) in preterm infants is still controversial, particularly in the developing world. MATERIALS AND METHODS One hundred twenty-two preterm infants were enrolled in the study. The multivariate logistic regression model was used to identify potential postnatal risk factors associated with NEC. RESULTS Preterm infants (n = 51) with total NEC, medical NEC, and surgical NEC had the highest rate of receiving ranitidine compared with controls (n = 71) (39.2%, 19.6%, and 47.6%, p < 0.05). Logistic regression analysis revealed that ranitidine use and nosocomial infections were significantly associated with NEC development (odds ratios 1.55 and 3.3). CONCLUSIONS We confirm that ranitidine administration was associated with an increased risk of NEC in preterm infants. H2-blockers use should be only administered in very strictly selected cases after careful consideration of the risk-benefit ratio.
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Affiliation(s)
- Zlatan Zvizdic
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Emir Milisic
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Asmir Jonuzi
- Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sabina Terzic
- Pediatric Clinic, Neonatal Intensive Care Unit, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Denisa Zvizdic
- Eye Clinic, Department of Pediatric Ophthalmology, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Vranic
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar. .,College of Medicine, QU Health, Qatar University, Doha, Qatar.
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Liau LL, Al-Masawa ME, Koh B, Looi QH, Foo JB, Lee SH, Cheah FC, Law JX. The Potential of Mesenchymal Stromal Cell as Therapy in Neonatal Diseases. Front Pediatr 2020; 8:591693. [PMID: 33251167 PMCID: PMC7672022 DOI: 10.3389/fped.2020.591693] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Mesenchymal stromal cells (MSCs) can be derived from various tissue sources, such as the bone marrow (BMSCs), adipose tissue (ADSCs), umbilical cord (UC-MSCs) and umbilical cord blood (UCB-MSCs). Clinical trials have been conducted to investigate the potential of MSCs in ameliorating neonatal diseases, including bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC). In preclinical studies, MSC therapy has been tested for the treatment of various neonatal diseases affecting the heart, eye, gut, and brain as well as sepsis. Up to date, the number of clinical trials using MSCs to treat neonatal diseases is still limited. The data reported thus far positioned MSC therapy as safe with positive outcomes. However, most of these trials are still preliminary and generally smaller in scale. Larger trials with more appropriate controls and a longer follow-up period need to be conducted to prove the safety and efficacy of the therapy more conclusively. This review discusses the current application of MSCs in treating neonatal diseases, its mechanism of action and future direction of this novel therapy, including the potential of using MSC-derived extracellular vesicles instead of the cells to treat various clinical conditions in the newborn.
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Affiliation(s)
- Ling Ling Liau
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Maimonah Eissa Al-Masawa
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Benson Koh
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Qi Hao Looi
- Future Cytohealth Sdn Bhd, Bandar Seri Petaling, Kuala Lumpur, Malaysia
| | - Jhi Biau Foo
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Sau Har Lee
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Fook Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Jia Xian Law
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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