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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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2
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Nicolas CT, Carter SR, Martin CA. Impact of maternal factors, environmental factors, and race on necrotizing enterocolitis. Semin Perinatol 2023; 47:151688. [PMID: 36572622 DOI: 10.1016/j.semperi.2022.151688] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology. As the leading cause of intestinal morbidity and mortality among premature infants, many resources are being dedicated to neonatal care and molecular targets in the newborn intestine. However, NEC is heavily influenced by maternal and perinatal factors as well. Given its nature, preventive approaches to NEC are more likely to improve outcomes than new treatment strategies. Therefore, this review focuses on maternal, environmental, and racial factors associated with the development of NEC, with an emphasis on those that may be modifiable to decrease the incidence of the disease.
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Affiliation(s)
- Clara T Nicolas
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Stewart R Carter
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY, United States
| | - Colin A Martin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General and Thoracic Surgery, Children's of Alabama, Birmingham, AL, United States.
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Robinson DT, Taylor SN, Moya F. Preterm infant nutrition: considerations for infants at risk of refeeding syndrome. J Perinatol 2023; 43:120-123. [PMID: 36414735 DOI: 10.1038/s41372-022-01531-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022]
Abstract
Refeeding syndrome (RS) in preterm infants is a scenario of fetal malnutrition, primarily resulting from placental insufficiency, followed by a postnatal physiologic adaptation and response to an imbalance of nutrients provided parenterally. Growth restriction and small gestational age status are common findings in infants at risk of developing RS. Adverse clinical outcomes associated with RS may be severe and life-threatening. The biochemical abnormalities that occur in RS may be mitigated through careful monitoring and adaptation of the clinical management of parenteral and enteral nutrition. This perspective reviews the physiology and metabolism in infants with RS and provides suggested approaches to their clinical monitoring and nutritional management.
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Affiliation(s)
- Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Sarah N Taylor
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Fernando Moya
- Department of Pediatrics, University of North Carolina School of Medicine, Wilmington, NC, USA
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Association between Abnormal Antenatal Doppler Characteristics and Gastrointestinal Outcomes in Preterm Infants. Nutrients 2022; 14:nu14235121. [PMID: 36501150 PMCID: PMC9738995 DOI: 10.3390/nu14235121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Antenatal Doppler disturbances are associated with fetal hypoxia and may induce a brain-sparing vascular redistribution at the expense of splanchnic circulation, possibly predisposing to gut complications. We aimed to compare several gastrointestinal outcomes among very-low-birthweight (VLBW) preterm infants with different antenatal Doppler features. VLBW infants born between 2010-2022 were retrospectively included and stratified into the following clusters based on antenatal Doppler characteristics: normal Doppler (controls); absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) alone or also in the ductus venosus (UA+DV-AREDF); and abnormal Doppler with or without brain-sparing redistribution. The following outcomes were evaluated: time to reach full enteral feeds (FEF), feeding intolerance (FI), necrotizing enterocolitis (NEC), and spontaneous intestinal perforation (SIP). Overall, 570 infants were included. Infants born following UA+DV-AREDF had significantly higher FI, NEC, and SIP rates and achieved FEF later compared to controls. Increased FI prevalence and a longer time to FEF compared to controls were also observed among UA-AREDF infants and in the presence of brain-sparing redistribution, which also increased NEC rates. Antenatal Doppler abnormalities exacerbate the gastrointestinal risks of preterm infants. Detailed knowledge of Doppler features can aid in identifying those at highest risk of intestinal complications who may benefit from tailored enteral feeding management.
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Gandecha H, Kaur A, Sanghera R, Preece J, Pillay T. Nutrition and Immunity in Perinatal Hypoxic-Ischemic Injury. Nutrients 2022; 14:nu14132747. [PMID: 35807927 PMCID: PMC9269416 DOI: 10.3390/nu14132747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/23/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023] Open
Abstract
Perinatal hypoxia ischaemia (PHI), acute and chronic, may be associated with considerable adverse outcomes in the foetus and neonate. The molecular and cellular mechanisms of injury and repair associated with PHI in the perinate are not completely understood. Increasing evidence is mounting for the role of nutrients and bioactive food components in immune development, function and repair in PHI. In this review, we explore current concepts around the neonatal immune response to PHI with a specific emphasis on the impact of nutrition in the mother, foetus and neonate.
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Affiliation(s)
- Hema Gandecha
- Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
- East Midlands Deanery, Health Education England, Leicester LE3 5DR, UK
| | - Avineet Kaur
- Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
- East Midlands Deanery, Health Education England, Leicester LE3 5DR, UK
| | - Ranveer Sanghera
- Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
- East Midlands Deanery, Health Education England, Leicester LE3 5DR, UK
| | - Joanna Preece
- Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
| | - Thillagavathie Pillay
- Department of Neonatology, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
- Faculty of Science and Engineering, Research Institute for Healthcare Sciences, University of Wolverhampton, Wolverhampton WV1 1LY, UK
- College of Life Sciences, University of Leicester, Leicester LE5 4PW, UK
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Fetal Doppler Evaluation to Predict NEC Development. J Pers Med 2022; 12:jpm12071042. [PMID: 35887539 PMCID: PMC9323983 DOI: 10.3390/jpm12071042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/16/2022] Open
Abstract
Antenatal factors play a role in NEC pathogenesis. This study aimed to investigate the predictive value of fetal ductus venosus doppler (DV) for NEC in fetal growth restriction fetuses (FGRF) and to assess the predictive accuracy of IG21 and Fenton curves in NEC development. Data from FGRF, postnatal findings, and Doppler characteristics were collected between 2010 and 2020 at a single center. Patients were then divided into two groups (i.e., with and without NEC). Bivariate and multivariate analyses were performed. We identified 24 cases and 30 controls. Absent or reversed end-diastolic flow (AREDF) and increased resistance in the DV were more impaired in cases (p < 0.05). Although the median birthweight was not different, the Fenton z-score was lower in NEC (p < 0.05). Fetal cardiopulmonary resuscitation, synchronized intermittent mandatory ventilation, neonatal respiratory distress, persistent patent ductus arteriosus (PDA), and inotropic support were more frequent in the NEC group. Furthermore, NEC patients had lower white blood cells (WBC) (p < 0.05). The predictive model for NEC (model 4), including Fenton z-score, WBC, PDA, and DV had an AUC of 84%. Fetal Doppler findings proved effective in predicting NEC in FGR. The Fenton z-score was the most predictive factor considering the fetal growth assessment showing high sensitivity.
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Mekonnen SM, Bekele DM, Fenta FA, Wake AD. The Prevalence of Necrotizing Enterocolitis and Associated Factors Among Enteral Fed Preterm and Low Birth Weight Neonates Admitted in Selected Public Hospitals in Addis Ababa, Ethiopia: A Cross-sectional Study. Glob Pediatr Health 2021; 8:2333794X211019695. [PMID: 34104696 PMCID: PMC8165834 DOI: 10.1177/2333794x211019695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
Necrotizing enterocolitis (NEC) remains to be the most critical and frequent gastrointestinal disorder understood in neonatal intensive care units (NICU). The presented study was intended to assess the prevalence of NEC and associated factors among enteral Fed preterm and low birth weight neonates. Institution based retrospective cross-sectional study was conducted on 350 enteral Fed preterm and low birth weight neonates who were admitted at selected public hospitals of Addis Ababa from March 25/2020 to May 10/2020. The data were collected through neonates' medical record chart review. A total of 350 participants were enrolled in to the study with the response rate of 99.43%. One hundred eighty-four (52.6%) of them were male. The majority 123 (35.1%) of them were (32 + 1 to 34) weeks gestational age. The prevalence of NEC was (25.4%) (n = 89, [95% CI; 21.1, 30.0]). Being ≤28 weeks gestational age (AOR = 3.94, 95% CI [2.67, 9.97]), being (28 + 1 to 32 weeks) gestational age (AOR = 3.65, 95% CI [2.21, 8.31]), birth weight of 1000 to 1499 g (AOR = 2.29, 95% CI [1.22, 4.33]), APGAR score ≤3 (AOR = 2.34, 95% CI [1.32, 4.16]), prolonged labor (AOR = 2.21, 95% CI [1.35, 6.38]), maternal chronic disease particularly hypertension (AOR = 3.2, 95% CI [1.70, 5.90]), chorioamnionitis (AOR = 4.8, 95% CI [3.9, 13]), failure to breath/resuscitated (AOR = 2.1, 95% CI [1.7, 4.4]), CPAP ventilation (AOR = 3.7, 95% CI [1.50, 12.70]), mixed milk (AOR = 3.58, 95% CI [2.16, 9.32]) were factors significantly associated with NEC. Finally, the prevalence of NEC in the study area was high. So that, initiating the programs that could minimize this problem is required to avoid the substantial morbidity and mortality associated with NEC.
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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Narendran N, Yusuf K. Fetal Doppler Assessment in Neonatal Care: Analysis of Fetal Doppler Abnormalities and Neonatal Outcomes. Neoreviews 2020; 20:e575-e583. [PMID: 31575779 DOI: 10.1542/neo.20-10-e575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fetal Doppler ultrasonography provides an effective and noninvasive approach to identify circulatory abnormalities in the maternal-fetal circulation. It is invaluable to assess the hemodynamic status of the fetus under a wide range of physiologic, infectious, and abnormal anatomic conditions. Findings from these studies are often used to make clinical decisions, including whether to proceed with urgent delivery of the fetus. In this review, we focus on key literature describing the main uses of Doppler ultrasonography in neonatal medicine, including how abnormal findings may be implicated in immediate and long-term outcomes. Our review highlights the importance of fetal Doppler examination as an effective intrauterine management strategy, and its full potential is more likely to be realized when considered in context with other available clinical information.
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Affiliation(s)
- Nadia Narendran
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kamran Yusuf
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
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10
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Association of initial empirical antibiotic therapy with increased risk of necrotizing enterocolitis. Eur J Pediatr 2020; 179:1047-1056. [PMID: 32424744 DOI: 10.1007/s00431-020-03679-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
Whether the prophylactic use of antibiotics increase the risk of necrotizing enterocolitis (NEC) remains controversial. This review aims to investigate initial empirical antibiotic therapy (IEAT) and is associated with the risk of NEC. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched through March 1, 2020. All studies on the impacts of antibiotic exposure on NEC development were included. Thirteen studies including 7901 participants were selected. Two reviewers independently examined the extracted data and assessed the quality of the included studies. Random-effects model was used to pool the effect estimates. We found that IEAT (≥ 5 days) was associated with an increased risk of NEC in adjusted (Odds risk [OR] 1.51, 95% confidence interval [CI] 1.22-1.87) and unadjusted (OR 2.35, 95% CI 1.54-3.57) analyses. Sensitivity analysis also supported these findings.Conclusion: The evidence suggests an association between IEAT (≥ 5 days) and the risk of NEC. Further studies are needed to address whether the association with IEAT is causal.What is Known:•Necrotizing enterocolitis (NEC) is acute inflammatory necrosis of the intestinal tractin the newborn infant.•Some observational studies have associated initial empirical antibiotics with an increased risk of subsequent NEC.What is New:•Initial empirical antibiotic therapy (IEAT) (≥ 5 days) appear to increase the risk of NEC.
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Color of Colon Content of Normal and Intrauterine Growth-Restricted Weaned Piglets is Associated with Specific Microbial Taxa and Physiological Parameters. Animals (Basel) 2020; 10:ani10061073. [PMID: 32580422 PMCID: PMC7341333 DOI: 10.3390/ani10061073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Selection for hyperprolific sows has increased litter sizes but has also increased the number of small piglets per litter. A large percentage of these piglets have been exposed to intrauterine growth restriction (IUGR) during gestation, and this is accompanied by higher mortality and reduced growth in pig production. In humans, IUGR is associated with long-term health consequences such as cardiovascular disease, as well as metabolic diseases such as type 2 diabetes. It is therefore of interest to study the gut microbiota (GM) of IUGR compared to normal piglets, as a well-balanced GM is associated with improved health outcomes. Differences in feces color was associated with different metabolite signatures and specific GM signatures. Understanding these differences in the composition of the microbial community and its functional capacity during weaning is important for pig production, as the GM play important roles in pig health and growth performance. Abstract A well-balanced gut microbiome is associated with improved health outcomes, but to date, the GM of IUGR piglets have only been sparsely investigated. Here, we investigated GM composition, color of colon content, and blood parameters of 20 IUGR and 20 normal 24-day-old piglets. No significant differences were detected in colon microbiota composition between IUGR and the normal piglets with respect to alpha and beta diversity measures. The colon content of these piglets displayed three colors: brown, black, and yellow. Interestingly, the color of the colon content varied with microbial community composition, with significant differences in the relative abundance of taxa belonging to Fusobacteria and Treponema. Fusobacteria were most abundant in yellow fecal samples, with a mean relative abundance around 5.6%, whereas this was 0.51% within brown and 0.02% for the black fecal samples. Fusobacteria positively correlated with total blood protein, albumin, and triglycerides. Contrarily, Treponema was at 0.9% the most abundant in black fecal samples, while present at 0.1% of relative abundance in brown fecal samples and 0.01% in yellow samples, correlating positively with blood iron content. This study indicates that colon/fecal content color can be used as indicator for specific GM and metabolite signatures.
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12
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Byun J, Han JW, Youn JK, Yang HB, Shin SH, Kim EK, Kim HY, Jung SE. Risk factors of meconium-related ileus in very low birth weight infants: patients-control study. Sci Rep 2020; 10:4674. [PMID: 32170203 PMCID: PMC7070079 DOI: 10.1038/s41598-020-60016-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/06/2020] [Indexed: 01/07/2023] Open
Abstract
Very low birth weight (VLBW) neonates experience various problems, including meconium-related ileus (MRI). This study investigated the risk factors of MRI and surgical MRI in VLBW infants. VLBW neonates admitted to the Neonatal Intensive Care Unit of Seoul National University Children's Hospital from October 2002 to September 2016 were included in the study. The diagnostic criteria for MRI were a decreased frequency of defecation with intolerable feeding, vomiting, and increased gastric residue (>50%); meconium-filled bowel dilatation in an imaging study; and no evidence of necrotizing enteritis or spontaneous intestinal perforation. Medical MRIs and surgical MRIs were managed through conventional treatment and surgical intervention. Of 1543 neonates, 69 and 1474 were in the patient and control groups, respectively. The risk factors for MRI include low birth weight (BW), cesarean section delivery, fetal distress, maternal diabetes, maternal hypertension, and maternal steroid use. Low BW and fetal distress were independent risk factors for MRI. Compared to the medical MRI group (n = 44), the risk factors for surgical MRI (n = 25) included males, younger gestational age, low BW, and meconium located at the small bowel. Male gender and low BW were independent risk factors for surgical MRI. Low BW and fetal distress were independent risk factors for MRI and male gender and low BW were independent risk factors for surgical MRI. In VLBW neonates, careful attention to the risk factors for MRI could minimize or avoid surgical interventions.
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Affiliation(s)
- Jeik Byun
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Won Han
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, South Korea
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13
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Maternal and placental risk factors associated with the development of necrotizing enterocolitis (NEC) and its severity. J Pediatr Surg 2019; 54:2099-2102. [PMID: 31084912 DOI: 10.1016/j.jpedsurg.2019.04.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND/PURPOSE Antenatal factors play an important role in NEC. This study aimed to identify antenatal risk factors associated with the development of NEC, the role of the placental alterations, and the presence of prenatal signs predisposing to a severe NEC. MATERIALS/METHODS Data of NEC patients including antenatal findings [preeclampsia, diabetes, cholestasis, abnormal antenatal umbilical artery flow (AAUF), clinical chorioamnionitis (CC), and histology of placentas] were compared to unaffected cases between 2002 and 2016 in a single center. Unaffected infants were matched for gestational age. Newborns with cardiovascular diseases were excluded. Bivariate and multivariate analyses were performed. RESULTS We identified 136 cases and 134 controls. The group of mothers of NEC-neonates had a higher prevalence of preeclampsia, CC, and AAUF. Histology of Placentas from 123/136 cases and 126/133 unaffected newborns was available. Chorioamnionitis was significantly more present in NEC cases vs controls. There weren't differences in vascular anomalies and necrotic alterations. Multivariate analysis identified AAUF, CC and histological chorioamnionitis (HC) as predictors of NEC. Bivariate tests show that preeclampsia and HC occurred more often in severe cases of NEC. CONCLUSION This study suggests that AAUF, CC, and HC can independently predict the risk of NEC. Preeclampsia and HC seem associated to more severe cases. LEVEL OF EVIDENCE IIIA.
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14
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Murphy T, Yang S, Tucker R, Collyer H, Kurkchubasche AG, Bender J. Necrotizing Enterocolitis and Spontaneous Intestinal Perforation: A Spatiotemporal Case Cluster Analysis. Pediatr Qual Saf 2019; 4:e127. [PMID: 30937409 PMCID: PMC6426488 DOI: 10.1097/pq9.0000000000000127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 11/07/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To expand existing statistical methods to identify clusters of necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) cases in the neonatal intensive care unit. METHODS In an academic, tertiary referral center, possible NEC or SIP clusters were identified using a binomial distribution scan test. The incidence-density rate (IDR) was calculated as the number of cases per 1,000 patient-days during each possible cluster and compared with the baseline IDR. A structured chart review compared cluster and noncluster cases. Spatial clustering analyzed the physical distribution of cases using the Grimson Test. Repeat analysis included only SIP cases. RESULT The initial scan identified 3 suspected temporal clusters. IDR comparison confirmed only 1 cluster. Analysis of SIP only cases revealed similar results. Physical proximity was not a significant factor. Chart review of the SIP and NEC cases revealed significant increases during the confirmed cluster of small for gestational age infant births and indomethacin treatment. Chart review of the SIP only cases in the confirmed cluster revealed no significant differences. CONCLUSION Statistical methods distinguish whether suspected case clusters represent a significant increase in baseline incidence. True clusters warrant detailed investigation including spatial analysis and chart review. This approach may have application in other disease processes and populations.
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Affiliation(s)
- Thomas Murphy
- From the Department of Pediatrics, Women & Infants Hospital, Alpert Medical School of Brown University
| | - Samuel Yang
- From the Department of Pediatrics, Women & Infants Hospital, Alpert Medical School of Brown University
| | - Richard Tucker
- From the Department of Pediatrics, Women & Infants Hospital, Alpert Medical School of Brown University
| | - Hillary Collyer
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Arlet G. Kurkchubasche
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Jesse Bender
- From the Department of Pediatrics, Women & Infants Hospital, Alpert Medical School of Brown University
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Zhang H, Li Y, Chen Y, Zhang L, Wang T. N-Acetylcysteine protects against intrauterine growth retardation-induced intestinal injury via restoring redox status and mitochondrial function in neonatal piglets. Eur J Nutr 2018; 58:3335-3347. [PMID: 30535793 DOI: 10.1007/s00394-018-1878-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Intrauterine growth retardation (IUGR) is detrimental to the intestinal development of neonates, yet satisfactory treatment strategies remain limited. This study was, therefore, conducted using neonatal piglets as a model to investigate the potential of N-acetylcysteine (NAC) to alleviate intestinal damage caused by IUGR. METHODS Seven normal birth weight (NBW) and fourteen IUGR neonatal male piglets were selected and then fed a basal milk diet (NBW-CON and IUGR-CON groups) or a basal milk diet supplemented with 1.2 g NAC per kg of diet (IUGR-NAC group) from 7 to 21 days of age (n = 7). Parameters associated with the severity of intestinal injury, villus morphology and ultrastructural structure, redox status, and mitochondrial function were analyzed. RESULTS Compared with the NBW-CON piglets, the IUGR-CON piglets exhibited decreased villus height and greater numbers of apoptotic cells in jejunum, along with the increases in malondialdehyde and protein carbonyl concentrations and a decreased adenosine triphosphate (ATP) content. Treatment with NAC significantly increased jejunal superoxide dismutase activity, reduced glutathione: oxidized glutathione ratio, and the mRNA abundance of nuclear respiratory factor 2, heme oxygenase 1, and superoxide dismutase 2 in the IUGR-NAC piglets compared with the IUGR-CON piglets. In addition, NAC improved the efficiency of mitochondrial oxidative metabolism and ATP generation, ameliorated mitochondrial swelling, and inhibited the overproduction of mitochondrial superoxide anion in the jejunal mucosa. CONCLUSIONS Dietary supplementation of NAC shows promise for attenuating the early intestinal injury of young piglets with IUGR, probably through its antioxidant action to restore redox status and mitochondrial function.
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Affiliation(s)
- Hao Zhang
- College of Animal Science and Technology, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, Jiangsu, People's Republic of China
- Postdoctoral Research Station of Clinical Veterinary Medicine, College of Veterinary Medicine, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, Jiangsu, People's Republic of China
- Shanghai Key Laboratory of Veterinary Biotechnology, Shanghai, 200240, People's Republic of China
| | - Yue Li
- Institute of Animal Science, Jiangsu Academy of Agricultural Sciences, 50 Zhongling Street, Nanjing, 210014, Jiangsu, People's Republic of China
| | - Yueping Chen
- College of Animal Science and Technology, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, Jiangsu, People's Republic of China
- Postdoctoral Research Station of Food Science and Engineering, College of Food Science and Technology, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, People's Republic of China
| | - Lili Zhang
- College of Animal Science and Technology, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, Jiangsu, People's Republic of China
| | - Tian Wang
- College of Animal Science and Technology, Nanjing Agricultural University, No. 1, Weigang Road, Nanjing, 210095, Jiangsu, People's Republic of China.
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Estimation of Neonatal Intestinal Perforation Associated with Necrotizing Enterocolitis by Machine Learning Reveals New Key Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112509. [PMID: 30423965 PMCID: PMC6267340 DOI: 10.3390/ijerph15112509] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022]
Abstract
Intestinal perforation (IP) associated with necrotizing enterocolitis (NEC) is one of the leading causes of mortality in premature neonates; with major nutritional and neurodevelopmental sequelae. Since predicting which neonates will develop perforation is still challenging; clinicians might benefit considerably with an early diagnosis tool and the identification of critical factors. The aim of this study was to forecast IP related to NEC and to investigate the predictive quality of variables; based on a machine learning-based technique. The Back-propagation neural network was used to train and test the models with a dataset constructed from medical records of the NICU; with birth and hospitalization maternal and neonatal clinical; feeding and laboratory parameters; as input variables. The outcome of the models was diagnosis: (1) IP associated with NEC; (2) NEC or (3) control (neither IP nor NEC). Models accurately estimated IP with good performances; the regression coefficients between the experimental and predicted data were R2 > 0.97. Critical variables for IP prediction were identified: neonatal platelets and neutrophils; orotracheal intubation; birth weight; sex; arterial blood gas parameters (pCO2 and HCO3); gestational age; use of fortifier; patent ductus arteriosus; maternal age and maternal morbidity. These models may allow quality improvement in medical practice.
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Conde-Agudelo A, Villar J, Kennedy SH, Papageorghiou AT. Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:430-441. [PMID: 29920817 DOI: 10.1002/uog.19117] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The cerebroplacental ratio (CPR) has been proposed for the routine surveillance of pregnancies with suspected fetal growth restriction (FGR), but the predictive performance of this test is unclear. The aim of this study was to determine the accuracy of CPR for predicting adverse perinatal and neurodevelopmental outcomes in suspected FGR. METHODS PubMed, EMBASE, CINAHL and Lilacs were searched from inception to 31 July 2017 for cohort or cross-sectional studies reporting on the accuracy of CPR for predicting adverse perinatal and/or neurodevelopmental outcomes in singleton pregnancies with FGR suspected antenatally based on sonographic parameters. Summary receiver-operating characteristics (ROC) curves, pooled sensitivities and specificities, and summary likelihood ratios (LRs) were generated. RESULTS Twenty-two studies (including 4301 women) met the inclusion criteria. Summary ROC curves showed that the best predictive accuracy of CPR was for perinatal death and the worst was for neonatal acidosis, with areas under the summary ROC curves of 0.83 and 0.57, respectively. The predictive accuracy of CPR was moderate to high for perinatal death (pooled sensitivity and specificity of 93% and 76%, respectively, and summary positive and negative LRs of 3.9 and 0.09, respectively) and low for composite of adverse perinatal outcomes, Cesarean section for non-reassuring fetal status, 5-min Apgar score < 7, admission to the neonatal intensive care unit, neonatal acidosis and neonatal morbidity, with summary positive and negative LRs ranging from 1.1 to 2.5 and 0.3 to 0.9, respectively. An abnormal CPR result had moderate accuracy for predicting small-for-gestational age at birth (summary positive LR of 7.4). CPR had a higher predictive accuracy in pregnancies with suspected early-onset FGR. No study provided data for assessing the predictive accuracy of CPR for adverse neurodevelopmental outcome. CONCLUSION CPR appears to be useful in predicting perinatal death in pregnancies with suspected FGR. Nevertheless, before incorporating CPR into the routine clinical management of suspected FGR, randomized controlled trials should assess whether the use of CPR reduces perinatal death or other adverse perinatal outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | - J Villar
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, Oxford, UK
| | - S H Kennedy
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, Oxford, UK
| | - A T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, Oxford, UK
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18
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Tewari VV, Dubey SK, Kumar R, Vardhan S, Sreedhar CM, Gupta G. Early versus Late Enteral Feeding in Preterm Intrauterine Growth Restricted Neonates with Antenatal Doppler Abnormalities: An Open-Label Randomized Trial. J Trop Pediatr 2018; 64:4-14. [PMID: 28369652 DOI: 10.1093/tropej/fmx018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND OF THE STUDY Enteral feeding in preterm neonates with intrauterine growth restriction (IUGR) and absent or reversed end diastolic flow (AREDF) on umbilical artery (UA) Doppler is delayed owing to an increased risk of necrotizing enterocolitis (NEC). Delaying enteral feeding with longer duration of parenteral nutrition (PN) carries an increased risk of sepsis. OBJECTIVES To study early versus late feeding in preterm IUGR neonates for time required to attain sufficient feed volume to discontinue PN and increased risk of NEC or feed intolerance (FI). DESIGN Open-label randomized controlled trial. SETTING Tertiary care neonatal unit and fetal-maternal medicine unit in India. PARTICIPANTS Preterm intrauterine growth restricted neonates' ≤32 weeks with AREDF on UA Doppler enrolled from 1 January 2014 to 31 July 2015. INTERVENTION Randomized to receive early or late feeding using mothers own or donor breast milk as per a feed initiation and advancement protocol. PRIMARY OUTCOME Time in days required to attain sufficient feed volume allowing discontinuation of PN and incidence of NEC in neonates fed early versus late. RESULTS There were 77 eligible neonates. Sixty-two neonates were included and stratified as extreme preterm (27-29 weeks) (n = 20) and very preterm (30-32 weeks) (n = 42). Ten extreme preterm and 21 very preterm neonates were randomized to each early feeding and late feeding arm. There was a significantly faster attainment of sufficient feeds in the early feeding arm of both the stratified groups [extreme preterm: median 14 days (Interquartile range IQR: 12-15) compared with 18 days (IQR: 18-20), hazard ratio (HR): 1.59, 95% CI: 0.626-4.078; very preterm: 12 days (IQR: 10-14) as compared with 16 days (IQR 15-17), HR: 1.89, 95% CI: 1.011-3.555]. There was no difference in the incidence of NEC, FI and combined outcome of NEC and FI. CONCLUSION Early feeding in preterm IUGR neonates with AREDF on antenatal UA Doppler allowed earlier discontinuation of PN, allowing birth weight to be regained earlier and did not increase the incidence of NEC and FI.
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Affiliation(s)
- Vishal Vishnu Tewari
- Department of Pediatrics, Army Hospital (Referral & Research), New Delhi-110010, India
| | - Sachin Kumar Dubey
- Department of Pediatrics, Army Hospital (Referral & Research), New Delhi-110010, India
| | - Reema Kumar
- Department of Obstetrics & Gynecology, Army Hospital (Referral & Research), New Delhi-110010, India
| | - Shakti Vardhan
- Department of Obstetrics & Gynecology, Army Hospital (Referral & Research), New Delhi-110010, India
| | - C M Sreedhar
- Department of Radiodiagnosis, Army Hospital (Referral & Research), New Delhi-110010, India
| | - Girish Gupta
- Department of Pediatrics, INHS Sanjeevani, Cochin-682004, India
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Wang C, Zhang R, Zhou L, He J, Huang Q, Siyal FA, Zhang L, Zhong X, Wang T. Intrauterine growth retardation promotes fetal intestinal autophagy in rats via the mechanistic target of rapamycin pathway. J Reprod Dev 2017; 63:547-554. [PMID: 28855439 PMCID: PMC5735265 DOI: 10.1262/jrd.2017-050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Intrauterine growth retardation (IUGR) impairs fetal intestinal development, and is associated with high perinatal morbidity and mortality. However, the mechanism underlying this intestinal injury is largely unknown. We aimed to
investigate this mechanism through analysis of intestinal autophagy and related signaling pathways in a rat model of IUGR. Normal weight (NW) and IUGR fetuses were obtained from primiparous rats via ad libitum
food intake and 50% food restriction, respectively. Maternal serum parameters, fetal body weight, organ weights, and fetal blood glucose were determined. Intestinal apoptosis, autophagy, and the mechanistic target of rapamycin
(mTOR) signaling pathway were analyzed. The results indicated that maternal 50% food restriction reduced maternal serum glucose, bilirubin, and total cholesterol and produced IUGR fetuses, which had decreased body weight; blood
glucose; and weights of the small intestine, stomach, spleen, pancreas, and kidney. Decreased Bcl-2 and increased Casp9 mRNA expression was observed in IUGR fetal intestines. Analysis of
intestinal autophagy showed that the mRNA expression of WIPI1, MAP1LC3B, Atg5, and Atg14 was also increased, while the protein levels of p62 were decreased in
IUGR fetuses. Compared to NW fetuses, IUGR fetuses showed decreased mTOR protein levels and enhanced mRNA expression of ULK1 and Beclin1 in the small intestine. In summary, the results indicated
that maternal 50% food restriction on gestational days 10–21 reduced maternal serum glucose, bilirubin, and total cholesterol contents, and produced IUGR fetuses that had low blood glucose and reduced small intestine weight.
Intestinal injury of IUGR fetuses caused by maternal food restriction might be due to enhanced apoptosis and autophagy via the mTOR signaling pathway.
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Affiliation(s)
- Chao Wang
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Ruiming Zhang
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Le Zhou
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Jintian He
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Qiang Huang
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Farman A Siyal
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Lili Zhang
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Xiang Zhong
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
| | - Tian Wang
- College of Animal Science and Technology, Nanjing Agricultural University, Nanjing 210095, People's Republic of China
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The clinical significance of an estimated fetal weight below the 10th percentile: a comparison of outcomes of <5th vs 5th-9th percentile. Am J Obstet Gynecol 2017; 217:198.e1-198.e11. [PMID: 28433732 DOI: 10.1016/j.ajog.2017.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/08/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The association between small-for-gestational-age (birthweight <10th percentile for gestational age) and neonatal morbidity is well established. Yet, there is a paucity of data on the relationship between suspected small for gestational age (sonographic-estimated fetal weight <10th percentile) at 2 thresholds and subsequent neonatal morbidity. OBJECTIVE The objective of this study was to determine the relationship between sonographic-estimated fetal weight <5th percentile vs 5-9th percentile and neonatal morbidity. STUDY DESIGN This retrospective study involved 5 centers and included nonanomalous, singletons with sonographic-estimated fetal weight <10th percentile for gestational age who delivered from 2009-2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis, thrombocytopenia, seizures, or death. Odd ratios were adjusted for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs, and neonatal gender. RESULTS Of 834 women with suspected small-for-gestational-age fetuses, 513 (62%) had sonographic-estimated fetal weight <5th percentile, and 321 (38%) had sonographic-estimated fetal weight of 5-9th percentile for gestational age. At delivery, 81% of women with a suspected small-for-gestational-age fetus had a confirmed small-for-gestational-age fetus. In the group with a sonographic-estimated fetal weight <5th percentile, 59% of neonates had birthweight <5th percentile; in the group with a sonographic-estimated fetal weight 5-9th percentile, 41% had birthweight <5th percentile, and 36% had birthweight at 5-9th percentile. Neonatal intensive care unit admission differed significantly for those fetuses at <5th percentile (29%) compared with those fetuses at 5-9th percentile (15%; P<.001). The composite neonatal morbidity among the sonographic-estimated fetal weight <5th percentile group was higher than the sonographic-estimated fetal weight of 5-9th percentile group (31% vs 13%; adjusted odds ratio, 2.41; 95% confidence interval, 1.53-3.80). Similar findings were noted when the analysis was limited to sonographic-estimated fetal weight within 28 days of delivery (adjusted odds ratio, 2.22; 95% confidence interval, 1.34-3.67). CONCLUSION Eight of 10 suspected small-for-gestational-age fetuses had birthweight <10th percentile for gestational age; the prediction of actual birthweight was more accurate in the <5th percentile group. Neonates with sonographic-estimated fetal weight of <5th percentile were more likely to be admitted to the neonatal intensive care unit and have complications than were those neonates with sonographic-estimated fetal weight of 5-9th percentile.
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21
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Risk factors for necrotizing enterocolitis in neonates: a systematic review of prognostic studies. BMC Pediatr 2017; 17:105. [PMID: 28410573 PMCID: PMC5391569 DOI: 10.1186/s12887-017-0847-3] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/23/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a severe multifactorial disease in preterm neonates associated with high morbidity and mortality. Better insight into prognostic values of the many reported factors associated with NEC is needed to enable identification of neonates at risk for NEC. The aim was to systematically review the literature to identify independent risk factors for NEC from the literature. METHODS Medline, Cochrane, Embase, Pubmed and Google Scholar were searched systematically for cohort studies reporting prognostic factors for NEC in neonates using multivariable analysis. Studies were scored with the Quality In Prognosis Studies tool (QUIPS). RESULTS From 5154 initial hits, 14 prognostic studies were included, with various designs. Study quality was rated high in three studies, moderate or low in the 11 others. Significant prognostic factors for NEC reported in at least two studies were: low birth weight, small for gestational age, low gestational age, assisted ventilation, premature rupture of membranes, black ethnicity, sepsis, outborn, hypotension (all increased risk), surfactant therapy (conflicting results) and cesarean section (lower risk). Meta-analysis was considered not feasible. CONCLUSION High quality studies on prognostic factors for NEC are rare. Several prognostic factors, that are not necessarily causal, are associated with NEC. High quality prognostic research is necessary to establish the predictive values of these factors.
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Ahamed MF, Dar P, Vega M, Kim M, Gao Q, Havranek T. Early feeding tolerance in small for gestational age infants with normal versus abnormal antenatal Doppler characteristics. J Neonatal Perinatal Med 2017; 10:43-48. [PMID: 28304325 DOI: 10.3233/npm-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine differences in feeding tolerance amongst preterm small for gestational age (SGA) infants with normal versus abnormal umbilical artery Doppler flow defined as absent or reversed end diastolic flow (AREDF). METHODS This was a retrospective cohort study of infants <35 weeks gestational age (GA) and birth weight (BW) <10th percentile. Day of initiation of feeds, days to full feeds and CRIB II scores were the primary outcomes. Clinical characteristics were compared between the groups of SGA infants with normal and AREDF. Multivariable regression models were fit to the data to adjust for potential confounders of the association of AREDF and feeding intolerance. RESULTS 120 infants with normal and 64 infants with AREDF were included. The infants with AREDF were smaller (971 g vs. 1183 g, p = 0.0002), less mature (29.9 wks vs. 31.2 wks, p = 0.0009), had higher CRIB II score (7.2 vs. 5.2, p = 0.0033), started feeding later (4.1 days vs. 3.3 days, p = 0.020) and advanced slower to full feeds (17.7 days vs. 13.7 days, p = 0.0017). Necrotizing enterocolitis was similar between the groups (p = 0.18). After adjusting for confounders, Doppler flow was no longer a significant predictor of the initiation (p = 0.37) and advancement of feeds (p = 0.44). CONCLUSIONS Infants with AREDF are sicker at birth and have more feeding difficulties; after adjusting for BW and GA, Doppler flow was no longer a significant predictor of feeding intolerance.
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Affiliation(s)
- M F Ahamed
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Southern Illinois University School of Medicine, IL, USA
| | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Division of Fetal Medicine and OBGYN Ultrasound, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - M Vega
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, NY, USA
| | - Mimi Kim
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, NY, USA
| | - Q Gao
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, NY, USA
| | - T Havranek
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, NY, USA
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23
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Meldere I, Urtans V, Petersons A, Abola Z. Measurement of abdominal circumference in preterm infants. BMC Res Notes 2015; 8:725. [PMID: 26611149 PMCID: PMC4661962 DOI: 10.1186/s13104-015-1657-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/02/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Body weight, length and head and thoracic circumference are routinely measured in obstetric and neonatal departments. Reference values for these measurements have been established for the neonatal population. Neonatal abdominal circumference is not routinely measured, and no reference values for this measurement have been determined. To evaluate the increase in abdominal circumference in newborns with abdominal pathology such as necrotizing enterocolitis, information about normal abdominal circumference in healthy neonates shortly after birth is needed. The aim of this study was to determine the correlation between abdominal circumference and birth weight by measuring the abdominal circumference of premature neonates soon after birth. METHODS Abdominal circumference was measured within 30 min of birth in 220 neonates born between 23 and 35 weeks' gestation. RESULTS There was no statistically significant difference in abdominal circumference between boys and girls in the study population. A specific formula for estimating normal abdominal circumference was developed: y = 0.0053x + 14.83 (y = abdominal circumference in cm; x = body weight in g; 0.0053 = regression coefficient; 14.83 = regression constant). CONCLUSION A positive linear correlation between abdominal circumference and birth weight was found in infants at birth. The correlation can be summarized as a linear regression equation. Further studies are needed to investigate possible factors associated with abdominal circumference in fed versus unfed preterm infants.
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Affiliation(s)
- Ilze Meldere
- Children's Clinical University Hospital, Riga, Latvia.
| | - Valdis Urtans
- Pauls Stradins Clinical University Hospital, Riga, Latvia.
| | - Aigars Petersons
- Children's Clinical University Hospital, Riga, Latvia. .,Department of Paediatric Surgery, Riga Stradins University, Riga, Latvia.
| | - Zane Abola
- Children's Clinical University Hospital, Riga, Latvia. .,Department of Paediatric Surgery, Riga Stradins University, Riga, Latvia.
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March MI, Gupta M, Modest AM, Wu L, Hacker MR, Martin CR, Rana S. Maternal risk factors for neonatal necrotizing enterocolitis. J Matern Fetal Neonatal Med 2014; 28:1285-1290. [PMID: 25162307 DOI: 10.3109/14767058.2014.951624] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study aimed to investigate the relationship between maternal hypertensive disease and other risk factors and the neonatal development of necrotizing enterocolitis (NEC). METHODS This was a retrospective case-control study of infants with NEC from 2008 to 2012. The primary exposure of interest was maternal hypertensive disease, which has been hypothesized to put infants at risk for NEC. Other variables collected included demographics, pregnancy complications, medications and neonatal hospital course. Data were abstracted from medical records. RESULTS Twenty-eight cases of singleton neonates with NEC and 81 matched controls were identified and analyzed. There was no significant difference in the primary outcome. Fetuses with an antenatal diagnosis of growth restriction were more likely to develop NEC (p = 0.008). Infants with NEC had lower median birth weight than infants without NEC (p = 0.009). Infants with NEC had more late-onset sepsis (p = 0.01) and mortality before discharge (p = 0.001). CONCLUSIONS The factors identified by this case-control study that increased the risk of neonatal NEC included intrauterine growth restriction and lower neonatal birth weight. The primary exposure, hypertensive disease, did not show a significantly increased risk of neonatal NEC; however, there was a nearly two-fold difference observed. Our study was underpowered to detect the observed difference.
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Affiliation(s)
- Melissa I March
- a Department of Obstetrics and Gynecology and.,b Division of Maternal-Fetal Medicine , Beth Israel Deaconess Medical Center , Boston , MA , USA.,c Harvard Medical School , Boston , MA , USA , and
| | - Munish Gupta
- c Harvard Medical School , Boston , MA , USA , and.,d Department of Neonatology , Beth Israel Deaconess Medical Center , Boston , MA
| | | | - Lily Wu
- a Department of Obstetrics and Gynecology and.,c Harvard Medical School , Boston , MA , USA , and
| | - Michele R Hacker
- a Department of Obstetrics and Gynecology and.,c Harvard Medical School , Boston , MA , USA , and
| | - Camilia R Martin
- c Harvard Medical School , Boston , MA , USA , and.,d Department of Neonatology , Beth Israel Deaconess Medical Center , Boston , MA
| | - Sarosh Rana
- a Department of Obstetrics and Gynecology and.,b Division of Maternal-Fetal Medicine , Beth Israel Deaconess Medical Center , Boston , MA , USA.,c Harvard Medical School , Boston , MA , USA , and
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Abstract
BACKGROUND Several risk factors have been implicated in the development of necrotising enterocolitis (NEC). However, little has been reported on the risk factors for NEC in infants born in a setting where exposure to maternal human immunodeficiency virus (HIV) is prevalent. OBJECTIVES To determine maternal and infant characteristics associated with NEC in a setting with a high prevalence of HIV infection and to compare clinical presentation and mortality of NEC in HIV-exposed and unexposed infants. METHODS This was a retrospective, case-control study. Infants with a confirmed diagnosis of NEC, admitted between January 2005 and December 2008 were identified as cases. Two controls for each case were selected by matching them for birthweight, gestational age and date of birth. Hospital records were reviewed for maternal and infant characteristics. RESULTS One hundred and ten infants with confirmed NEC were identified and 220 were selected as controls. Median birthweight and gestational age were similar between cases and controls, (1370 and 1380 g, P = 0·96, and 31 weeks each, P = 0·62, respectively). Lack of use of antenatal corticosteroids (ANS) (OR 2·77, 95% CI 1·42-5·38, P = 0·003), presence of chorio-amnionitis (OR 7·28, 95% CI 2·16-24·51, P = 0·001) and not mechanically ventilated at birth (OR 3·54, 95% CI 1·29-9·69, P = 0·01) were independently associated with NEC. Maternal HIV status was not associated with NEC. Clinical presentation and mortality from NEC were similar between HIV-exposed and unexposed infants. CONCLUSIONS Infants who develop NEC were less likely to have received mechanical ventilation at birth, suggesting that they were less critically ill when born. Use of ANS should be encouraged as it is protective against NEC. Infants born to HIV-infected mothers were not at increased risk of NEC.
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Markel TA, Engelstad H, Poindexter BB. Predicting disease severity of necrotizing enterocolitis: how to identify infants for future novel therapies. J Clin Neonatol 2014; 3:1-9. [PMID: 24741531 PMCID: PMC3982330 DOI: 10.4103/2249-4847.128717] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Necrotizing enterocolitis (NEC) remains a very devastating problem within the very low birth weight neonatal population. Several experimental therapies are being tested in animal models and soon may be ready for human trials. Despite this progress, we currently have no way to identify infants who would be optimal targets for therapy. Specifically, we are unable to predict which infants will progress to the more severe Bell's stage of disease that may necessitate surgery. Ideally, an algorithm could be constructed that would encompass multiple neonatal and maternal risk factors as well as potential biologic markers of disease so that these infants could be identified in a more timely fashion. This review summarizes the known risk factors and biomarkers of disease in hopes of stimulating clinical research to identify such an “early warning” NEC algorithm.
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Affiliation(s)
- Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Holly Engelstad
- Department of Pediatrics, Section of Neonatology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Section of Neonatology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Geary E. Risk of necrotizing enterocolitis and feeding interventions for preterm infants with abnormal umbilical artery Doppler. Neonatal Netw 2013; 32:5-15. [PMID: 23318202 DOI: 10.1891/0730-0832.32.1.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infants exposed to absent or reversed end-diastolic flow (ARE DF) in utero may be at an increased risk of developing necrotizing enterocolitis (NEC). This article reviews placental function and the development of ARE DF. Studies examining the relationship between AREDF and NEC are reviewed, yet research remains inconclusive regarding this relationship. Recent studies reveal that early minimal enteral feeding does not increase the incidence of NEC in infants with AREDF. Initiation and advancement of enteral feedings should be monitored closely in this subset of the neonatal intensive care unit (NICU) population.
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Affiliation(s)
- Erin Geary
- Pediatrix Medical Group, Baylor South Dallas, Dallas, TX 75205, USA.
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Barone G, Maggio L, Saracino A, Perri A, Romagnoli C, Zecca E. How to feed small for gestational age newborns. Ital J Pediatr 2013; 39:28. [PMID: 23663313 PMCID: PMC3660241 DOI: 10.1186/1824-7288-39-28] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 05/08/2013] [Indexed: 06/18/2023] Open
Abstract
Feeding small for gestational age (SGA) newborns is extremely challenging and the neonatologist should be brave and cautious at the same time. Although these babies have a high risk of milk intolerance and necrotising enterocolitis, enteral feeding guidelines are not well established and practice varies widely among different neonatal units. Currently available studies on this topic include extremely and very low birth weight neonates, but are not focused specifically on small for gestational age infants. This review analyzes papers focused on feeding interventions in order to provide the best available evidences about the optimum timing for introduction of enteral feeding, how fast feed volume can be advanced, which milk and which feeding method is more appropriate in SGA infants.
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Affiliation(s)
- Giovanni Barone
- Division of Neonatology, Department of Pediatrics, Catholic University Sacred Heart, Largo A, Gemelli 8, Rome 00168, Italy.
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Abdelmaaboud M, Mohammed A. Early Versus Late Minimal Enteral Feeding in Weeks Preterm Growth-Restricted neonates with Abnormal Antenatal Doppler Studies. J Matern Fetal Neonatal Med 2012:1-20. [PMID: 23211122 DOI: 10.3109/14767058.2012.695821] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Background: Preterm and growth-restricted babies are at high risk of milk intolerance and necrotising enterocolitis, as well as post-natal growth failure. Objective: To evaluate the effects of an "early" enteral feeding regimen, starting on day 2 after birth compared to late enteral feeding, starting on day 6 after birth in preterm growth restricted babies with abnormal antenatal Doppler studies regarding the incidence of NEC and feeding intolerance. Patients and Methods: Babies with gestational age below 37 weeks, and with birth weight below 10th centile for gestational age, will be randomly allocated to an "early" or "late" enteral feeding regimen. Results: Hundred-thirty three infants enrolled in the study: 66 received early feeding and 67 received delayed feeding. The incidence of NEC and feeding intolerance was not significantly different between the two groups. Conclusion: Early minimal enteral feeding (MEF) of preterm infants with IUGR and abnormal antenatal Doppler results may not have a significant effect on the incidence of NEC or feeding intolerance.
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Downard CD, Grant SN, Maki AC, Krupski MC, Matheson PJ, Bendon RW, Fallat ME, Garrison RN. Maternal cigarette smoking and the development of necrotizing enterocolitis. Pediatrics 2012; 130:78-82. [PMID: 22689867 DOI: 10.1542/peds.2011-3808] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The maternal variables that affect fetal development and correlate with necrotizing enterocolitis (NEC), the most common gastrointestinal emergency in premature infants, are not well defined. We hypothesized that maternal risk factors were the primary determinant of future development of NEC. METHODS Patients with NEC were identified from an established NICU database and were control-matched with 2 neonates treated at the same institution. The medical records of each patient during the NICU admission as well as the prenatal and delivery record of the patient's mother were reviewed. Perinatal data, including maternal smoking, maternal hypertension, maternal BMI, maternal gestational diabetes, conduct of labor and type of delivery, Apgar scores, types of feedings, and placental pathology, were examined, with P < .05 deemed significant. RESULTS A total of 73 neonates diagnosed with NEC and 146 matched controls were identified. Medical records for each subject and their mothers were reviewed (438 records total). Maternal cigarette smoking was significantly associated with the future development of NEC (P = .02). Maternal gestational diabetes, maternal hypertension, formula feeding, and pathologic chorioamnionitis or uteroplacental insufficiency did not correlate with NEC. CONCLUSIONS These data identified maternal cigarette smoking as the only risk factor that is associated with the development of NEC in premature infants. Our data imply that smoking delivers toxins and nicotine to the uterine microenvironment that can affect microvascular development and may predispose the fetus to future NEC.
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Affiliation(s)
- Cynthia D Downard
- MMSc, Division of Pediatric Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky 40202, USA.
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Abstract
Necrotizing enterocolitis (NEC) is the most common cause of gastrointestinal-related morbidity and mortality in the neonatal intensive care unit (NICU). Its onset is sudden and the smallest, most premature infants are the most vulnerable. Necrotizing enterocolitis is a costly disease, accounting for nearly 20% of NICU costs annually. Necrotizing enterocolitis survivors requiring surgery often stay in the NICU more than 90 days and are among those most likely to stay more than 6 months. Significant variations exist in the incidence across regions and units. Although the only consistent independent predictors for NEC remain prematurity and formula feeding, others exist that could increase risk when combined. Awareness of NEC risk factors and adopting practices to reduce NEC risk, including human milk feeding, the use of feeding guidelines, and probiotics, have been shown to reduce the incidence of NEC. The purpose of this review is to examine the state of the science on NEC risk factors and make recommendations for practice and research.
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Lallès JP, Orozco-Solís R, Bolaños-Jiménez F, de Coppet P, Le Dréan G, Segain JP. Perinatal undernutrition alters intestinal alkaline phosphatase and its main transcription factors KLF4 and Cdx1 in adult offspring fed a high-fat diet. J Nutr Biochem 2012; 23:1490-7. [PMID: 22405696 DOI: 10.1016/j.jnutbio.2011.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 07/20/2011] [Accepted: 10/12/2011] [Indexed: 12/14/2022]
Abstract
Nutrient restriction during gestation and/or suckling is associated with an increased risk of developing inflammation, obesity and metabolic diseases in adulthood. However, the underlying mechanisms, including the role of the small intestine, are unclear. We hypothesized that intestinal adaptation to the diet in adulthood is modulated by perinatal nutrition. This hypothesis was tested using a split-plot design experiment with 20 controls and 20 intrauterine growth-retarded (IUGR) rats aged 240 days and randomly assigned to be fed a standard chow or a high-fat (HF) diet for 10 days. Jejunal tissue was collected at necropsy and analyzed for anatomy, digestive enzymes, goblet cells and mRNA levels. Cecal contents and blood serum were analyzed for alkaline phosphatase (AP). IUGR rats failed to adapt to HF by increasing AP activity in jejunal tissue and cecal content as observed in controls. mRNA levels of transcription factors KLF4 and Cdx1 were blunted in jejunal epithelial cell of IUGR rats fed HF. mRNA levels of TNF-α were lower in IUGR rats. They also displayed exacerbated aminopeptidase N response and reduced jejunal goblet cell density. Villus and crypt architecture and epithelial cell proliferation increased with HF in both control and IUGR rats. Serum AP tended to be lower, and serum levamisole inhibition-resistant AP fraction was lower, in IUGR than controls with HF. Serum fatty acids and triglycerides were higher in IUGR rats and higher with HF. In conclusion, the adult intestine adapts to an HF diet differentially depending on early nutrition, jejunal AP and transcription factors being blunted in IUGR individuals fed HF.
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Affiliation(s)
- Jean-Paul Lallès
- INRA, UMR1079, Systèmes d'Elevage, Nutrition Animale et Humaine, F-35000 Rennes, France.
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Raboisson MJ, Huissoud C, Lapointe A, Hugues N, Bigras JL, Brassard M, Lamoureux J, Fouron JC. Assessment of uterine artery and aortic isthmus Doppler recordings as predictors of necrotizing enterocolitis. Am J Obstet Gynecol 2012; 206:232.e1-6. [PMID: 22189049 DOI: 10.1016/j.ajog.2011.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 09/06/2011] [Accepted: 11/11/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate whether changes of uterine arteries and aortic isthmus Doppler blood flow recordings could enhance the prediction of necrotizing enterocolitis. STUDY DESIGN Doppler characteristics of the uterine artery, umbilical and middle cerebral arteries, ductus venosus, and aortic isthmus were reviewed in 123 growth-restricted fetuses who were then divided into 2 groups: with and without necrotizing enterocolitis. RESULTS Twelve of 123 newborn infants (9%) expressed necrotizing enterocolitis. This group showed significant association between necrotizing enterocolitis and bilateral notching on the uterine artery (83.3% vs 29.7%; P < .001), uterine artery mean resistance index (83.3% vs 36.9%; P < .002), aortic isthmus diastolic blood flow velocity integrals (Z score: -7.32 vs -3.99; P = .028), and absent or negative "a" wave on the ductus venosus (17% vs 1.8%; P = .021). With the use of logistic regression, uterine bilateral notching could predict necrotizing enterocolitis with a sensitivity of 83.3% and a specificity of 70.3%. CONCLUSION More than any other variable, uterine bilateral notching should be recognized as a strong risk factor for necrotizing enterocolitis.
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Abstract
PURPOSE OF REVIEW Necrotizing enterocolitis (NEC) remains the most common serious acquired gastrointestinal disorder affecting preterm infants. Here we review recent advances in our understanding of the pathogenesis of this multifactorial condition and consider the implications for practice and research. RECENT FINDINGS NEC is an important cause of mortality and serious morbidity in preterm infants. The risk is inversely proportional to gestational age and weight at birth. Fetal growth restriction and compromise may be additional specific risk factors. NEC, particularly severe NEC requiring surgical intervention and NEC with invasive infection, is associated with acute morbidity and mortality and adverse neurodevelopmental outcomes. The principal modifiable postnatal risk factors for NEC in preterm infants relate to enteral feeding practices including formula milk feeding, early and rapid advancement of enteral feed volumes, and exposure to H2-receptor antagonists. SUMMARY Our understanding of the pathogenesis of this condition remains incomplete. With the exception of feeding with human milk, only limited evidence is currently available to support interventions to prevent NEC. Promising strategies that merit further evaluation in randomized controlled trials include the use of prebiotics and probiotics and the avoidance of exposure to H2-receptor antagonists.
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Singh R, Visintainer PF, Frantz ID, Shah BL, Meyer KM, Favila SA, Thomas MS, Kent DM. Association of necrotizing enterocolitis with anemia and packed red blood cell transfusions in preterm infants. J Perinatol 2011; 31:176-82. [PMID: 21273983 PMCID: PMC3234132 DOI: 10.1038/jp.2010.145] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 09/16/2010] [Accepted: 09/17/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine association of anemia and red blood cell (RBC) transfusions with necrotizing enterocolitis (NEC) in preterm infants. STUDY DESIGN A total of 111 preterm infants with NEC ≥ stage 2a were compared with 222 matched controls. In all, 28 clinical variables, including hematocrit (Hct) and RBC transfusions were recorded. Propensity scores and multivariate logistic regression models were created to examine effects on the risk of NEC. RESULT Controlling for other factors, lower Hct was associated with increased odds of NEC (odds ratio (OR)=1.10, P=0.01). RBC transfusion has a temporal relationship with NEC onset. Transfusion within 24 h (OR=7.60, P=0.001) and 48 h (OR=5.55, P=0.001) has a higher odds of developing NEC but this association is not significant by 96 h (OR=2.13, P=0.07), post-transfusion. CONCLUSION Anemia may increase the risk of developing NEC in preterm infants. RBC transfusions are temporally related to NEC. Prospective studies are needed to better evaluate the potential influence of transfusions on the development of NEC.
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Affiliation(s)
- R Singh
- Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA 01199, USA.
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36
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Chander L, Sonal G. Colour Doppler in IUGR- Where are we and where do we go? J Obstet Gynaecol India 2010. [DOI: 10.1007/s13224-010-0047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Morris RK, Selman TJ, Verma M, Robson SC, Kleijnen J, Khan KS. Systematic review and meta-analysis of the test accuracy of ductus venosus Doppler to predict compromise of fetal/neonatal wellbeing in high risk pregnancies with placental insufficiency. Eur J Obstet Gynecol Reprod Biol 2010; 152:3-12. [PMID: 20493624 DOI: 10.1016/j.ejogrb.2010.04.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 03/08/2010] [Accepted: 04/26/2010] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the test accuracy of ductus venosus Doppler for prediction of compromise of fetal/neonatal wellbeing. STUDY DESIGN The search strategy employed searching of electronic databases (Medline, Embase, Cochrane library, Medion) from inception to May 2009, hand searching of journal and reference lists, contact with experts. Two reviewers independently selected articles in which the results of ductus venosus Doppler were associated with the occurrence of compromise of fetal/neonatal wellbeing. There were no language restrictions applied. Data were extracted on study characteristics, quality and results to construct 2 x 2 tables. Likelihood ratios for positive and negative test results, sensitivity, specificity and their 95% confidence intervals were generated for the different indices and thresholds. RESULTS Eighteen studies, testing 2267 fetuses met the selection criteria, all performed in a high risk population with placental insufficiency in second/third trimester. Meta-analysis showed moderate predictive accuracy. The best result was for the prediction of perinatal mortality, positive likelihood ratio 4.21 (95% CI 1.98-8.96) and negative likelihood ratio 0.43 (95% CI 0.30-0.61). For prediction of adverse perinatal outcome the results were positive likelihood ratio 3.15 (95% CI 2.19-4.54) and negative likelihood ratio 0.49 (95% CI 0.40-0.59). CONCLUSION Abnormal ductus venosus Doppler showed moderate predictive accuracy for compromise of fetal/neonatal wellbeing overall and perinatal mortality in high risk pregnancies with placental insufficiency.
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Affiliation(s)
- R Katie Morris
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham Women's Hospital, Birmingham B15 2TG, UK.
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Dix L, Roth-Kleiner M, Osterheld MC. Placental vascular obstructive lesions: risk factor for developing necrotizing enterocolitis. PATHOLOGY RESEARCH INTERNATIONAL 2010; 2010:838917. [PMID: 21151528 PMCID: PMC2989861 DOI: 10.4061/2010/838917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 02/16/2010] [Accepted: 02/18/2010] [Indexed: 11/20/2022]
Abstract
Necrotizing enterocolitis (NEC) is a severe neonatal disease affecting particularly preterm infants. Its exact pathogenesis still remains unknown. In this study, we have compared the prevalence of vascular obstructive lesions in placentae of premature newborns which developed NEC and of a control group. We further compared separately the findings of placentae of infants of less than 30 weeks of gestation, the age group in which NEC occurs most frequently. We found signs of fetal vascular obstructive lesions in 65% of the placentae of preterm patients developing NEC, compared to only 17% of the placentae of preterm patients in the control group. In the age groups below 30 weeks of gestation, 58.5% of placentae of later NEC patients presented such lesions compared to 24.5% in the control group. The significant difference between NEC and control group suggests a strong association between fetal vascular obstructive lesions and NEC. Therefore, we propose that fetal vascular obstructive lesions might be considered as a risk factor for the development of NEC in premature infants.
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Affiliation(s)
- Laure Dix
- Institute of Pathology, University of Lausanne, CH-1011 Lausanne, Switzerland
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Che L, Thymann T, Bering SB, LE Huërou-Luron I, D'inca R, Zhang K, Sangild PT. IUGR does not predispose to necrotizing enterocolitis or compromise postnatal intestinal adaptation in preterm pigs. Pediatr Res 2010; 67:54-9. [PMID: 19816236 DOI: 10.1203/pdr.0b013e3181c1b15e] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
IUGR and preterm birth are leading causes of neonatal morbidity. We tested the hypothesis that IUGR predisposes to gut maladaption and necrotizing enterocolitis (NEC) using preterm pigs as models for preterm infants. First, full-term normal birth weight (NW) and IUGR ( approximately 65% of NW) pigs were compared. IUGR reduced intestinal weight per length, proportion mucosa, villous area, and sucrase activity at 2 d after birth (p < 0.05) but did not change relative organ weights. Next, groups of preterm pigs were fed formula or colostrum, starting at birth or after 2-3 d of total parenteral nutrition (TPN). Neonatal mortality (not related to NEC) was increased in IUGR versus NW preterm pigs (28 vs 10%, p < 0.01). NEC incidence was similar between IUGR and NW but higher after formula than colostrum feeding (46 vs 12%, p < 0.01) and higher after TPN than without TPN (61 vs 34% for formula pigs, p < 0.01). After feeding, relative intestinal mass and length were higher in IUGR versus NW pigs (+25-80%, p < 0.05) while brush border enzyme activities were similar. An enhanced gut trophic response to enteral feeding may help to improve postnatal intestinal adaptation and NEC resistance in preterm IUGR newborns.
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Affiliation(s)
- Lianqiang Che
- Institute of Animal Nutrition, Sichuan Agricultural University, Sichuan, 625014, People's Republic of China
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Wang KG, Chen CY, Chen YY. The Effects of Absent or Reversed End-diastolic Umbilical Artery Doppler Flow Velocity. Taiwan J Obstet Gynecol 2009; 48:225-31. [DOI: 10.1016/s1028-4559(09)60294-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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