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Barnett RC, Lewis AN, Gong Q, Preston DL, Frazer LC, Werthammer JW, Good M. Modulation of intestinal TLR4 expression in infants with neonatal opioid withdrawal syndrome. J Perinatol 2024; 44:1125-1131. [PMID: 38151596 PMCID: PMC11209831 DOI: 10.1038/s41372-023-01859-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/23/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Neonatal Opioid Withdrawal Syndrome (NOWS) has been associated with the development of necrotizing enterocolitis (NEC) in term and late-preterm neonates. In this study, we used stool gene expression to determine if an increase in baseline inflammation in the intestine of infants with NOWS is associated with these findings. STUDY DESIGN Stool samples were prospectively collected between days 1-3 and days 4-9 after delivery for opioid-exposed ( n = 9) or non-exposed neonates (n = 8). Stool gene expression for TLR4 and HMGB1 was determined via real-time PCR. RESULTS TLR4 expression was higher in the stool of the non-exposed group in both time periods, between days 1-3 (P < 0.0001) and days 4-9 (P < 0.05) after delivery. No significant difference in HMGB1 expression was found at either time point (P > 0.05). CONCLUSION These findings point to an important interplay between opioid exposure and/or NOWS and the inflammatory milieu of the neonatal intestine.
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Affiliation(s)
- Rebecca C Barnett
- Department of Pediatrics, Marshall University, Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Angela N Lewis
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Qingqing Gong
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Deborah L Preston
- Department of Pediatrics, Marshall University, Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Lauren C Frazer
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Joseph W Werthammer
- Department of Pediatrics, Marshall University, Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Misty Good
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA.
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill, NC, USA.
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2
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Gaillard J, Gu AR, Neil Knierbein EE. Necrotizing Enterocolitis following Onasemnogene Abeparvovec for Spinal Muscular Atrophy: A Case Series. J Pediatr 2023; 260:113493. [PMID: 37211209 DOI: 10.1016/j.jpeds.2023.113493] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
Onasemnogene abeparvovec treats spinal muscular atrophy by delivering a functional SMN1 gene. Necrotizing enterocolitis typically occurs in preterm infants. We report 2 term infants diagnosed with spinal muscular atrophy who presented with necrotizing enterocolitis after onasemnogene abeparvovec infusion. We discuss potential etiologies and propose monitoring for necrotizing enterocolitis after onasemnogene abeparvovec therapy.
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Affiliation(s)
- Jonathan Gaillard
- Division of Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Andrew Ran Gu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Erin E Neil Knierbein
- Division of Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
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3
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Kumar J, Anne RP, Meena J, Sundaram V, Dutta S, Kumar P. To feed or not to feed during therapeutic hypothermia in asphyxiated neonates: a systematic review and meta-analysis. Eur J Pediatr 2023:10.1007/s00431-023-04950-0. [PMID: 37014443 DOI: 10.1007/s00431-023-04950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023]
Abstract
The practice of withholding feed during therapeutic hypothermia (TH) in neonates with hypoxemic ischemic encephalopathy (HIE) is based on conventions rather than evidence. Recent studies suggest that enteral feeding might be safe during TH. We systematically compared the benefits and harms of enteral feeding in infants undergoing TH for HIE. We searched electronic databases and trial registries (MEDLINE, CINAHL, Embase, Web of Science, and CENTRAL) until December 15, 2022, for studies comparing enteral feeding and non-feeding strategies. We performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was the incidence of stage II/III necrotizing enterocolitis (NEC). Other outcomes included the incidence of any stage NEC, mortality, sepsis, feed intolerance, time to full enteral feeds, and hospital stay. Six studies ((two randomized controlled trials (RCTs) and four nonrandomized studies of intervention (NRSIs)) enrolling 3693 participants were included. The overall incidence of stage II/III NEC was very low (0.6%). There was no significant difference in the incidence of stage II/III NEC in RCTs (2 trials, 192 participants; RR, 1.20; 95% CI: 0.53 to 2.71, I2, 0%) and NRSIs (3 studies, no events in either group). In the NRSIs, infants in the enteral feeding group had significantly lower sepsis rates (four studies, 3500 participants, RR, 0.59; 95% CI: 0.51 to 0.67, I2-0%) and lower all-cause mortality (three studies, 3465 participants, RR: 0.43; 95% CI: 0.33 to 0.57, I2-0%) than the infants in the "no feeding" group. However, no significant difference in mortality was observed in RCTs (RR: 0.70; 95% CI: 0.28 to 1.74, I2-0%). Infants in the enteral feeding group achieved full enteral feeding earlier, had higher breastfeeding rates at discharge, received parenteral nutrition for a shorter duration, and had shorter hospital stays than the control group. Conclusion: In late preterm and term infants with HIE, enteral feeding appears safe and feasible during the cooling phase of TH. However, there is insufficient evidence to guide the timing of initiation, volume, and feed advancement. What is Known: • Many neonatal units withhold enteral feeding during therapeutic hypothermia, fearing an increased risk of complications (feed intolerance and necrotizing enterocolitis). • The overall risk of necrotizing enterocolitis in late-preterm and term infants is extremely low (< 1%). What is New: • Enteral feeding during therapeutic hypothermia is safe and does not increase the risk of necrotizing enterocolitis, hypoglycemia, or feed intolerance. It may reduce the incidence of sepsis and all-cause mortality until discharge.
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Affiliation(s)
- Jogender Kumar
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajendra Prasad Anne
- Department of Pediatrics, All India Institute of Medical Sciences, Bibi Nagar, Telangana, India
| | - Jitendra Meena
- Department of Pediatrics, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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4
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A Scoping Review of Neonatal Opioid Withdrawal and the Infant Gut Microbiome: Does Human Milk Optimize Infant Outcomes? Adv Neonatal Care 2023; 23:237-245. [PMID: 36867674 DOI: 10.1097/anc.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
BACKGROUND While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome. PURPOSE The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome. DATA SOURCES CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches. STUDY SELECTION Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome. DATA EXTRACTION Two authors independently conducted title/abstract and full-text review until there was consensus of study selection. RESULTS No studies satisfied the inclusion criteria, which resulted in an empty review. IMPLICATIONS FOR PRACTICE AND RESEARCH Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry.
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Pugh CP, Baber M, White G. Necrotizing enterocolitis following treatment of congenital syphilis with penicillin in a term newborn. SAGE Open Med Case Rep 2023; 11:2050313X231172672. [PMID: 37205159 PMCID: PMC10186574 DOI: 10.1177/2050313x231172672] [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: 11/29/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
Necrotizing enterocolitis is a disease process of intestinal disruption which has been associated with gastrointestinal microbial alterations after antibiotic exposure. Treatment guidelines and antibiotic exposure for congenital syphilis have historically been based on limited evidence. This case presents a term infant who developed necrotizing enterocolitis after treatment for congenital syphilis.
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Affiliation(s)
- Charles Preston Pugh
- Charles Preston Pugh, Department of Pediatrics,
University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 512-5B, Little
Rock, AR 72205, USA.
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White G, Dulaney B, Brown C, Baber M. Echogenic Bowel as an Indicator of Necrotizing Enterocolitis in a Term Newborn. Glob Pediatr Health 2022; 9:2333794X221142431. [PMCID: PMC9742684 DOI: 10.1177/2333794x221142431] [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: 10/31/2022] [Accepted: 11/12/2022] [Indexed: 12/13/2022] Open
Abstract
A 3.5-kilogram infant was born at 40 weeks gestation with an uncomplicated delivery. Prenatal ultrasounds showed echogenic bowel and a ventricular septal defect (VSD), of no clinical significance. Abdominal radiographs showed pneumatosis at 21, 36, and 48 hours of life (HOL). She was treated for necrotizing enterocolitis (NEC) with intravenous antibiotics and parenteral nutrition for 7 days, before working up on feeds and discharging home with breast milk. The only prenatal finding in this case was hyperechogenic bowel, which is a soft marker and often disregarded in the absence of other signs. Chronic intrauterine gut ischemia can cause hyperechogenicity of the bowel. That same intrauterine gut ischemia may have been responsible for NEC in our patient. If a patient has persistent echogenic bowel on prenatal imaging, a critical need exists to make sure NEC is not present.
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Affiliation(s)
- Gwenevere White
- University of Arkansas for Medical Sciences, Little Rock, AR, USA,Gwenevere White, Department of Pediatrics, Division of Neonatology, University of Arkansas for Medical Sciences, 4301 W Markham Street, Slot 512-5B, Little Rock, AR 72205, USA.
| | - Breyanna Dulaney
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Carla Brown
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan Baber
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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7
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Swanson JR, Hair A, Clark RH, Gordon PV. Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant. J Perinatol 2022; 42:423-429. [PMID: 35177793 DOI: 10.1038/s41372-022-01347-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/12/2022]
Abstract
Recent data have revealed declines in the prevalence rates of NEC over the last decade in premature infants. In contrast, SIP has either remained steady or risen during the same epoch. These trends are consistent with our knowledge of the clinical arena. The ability to discern SIP contamination within NEC datasets has slowly improved. Additionally, quality improvement efforts are being utilized to reduce NEC through stewardship of antibiotics, acid inhibitors, central lines and blood products, as well as optimization of human milk diets. These forces are moving us to a new era, where NEC will no longer be the dominant surgical intestinal disease of the extremely preterm neonate. Indeed, in the extremely low birth weight (ELBW) population, SIP may already be the most prevalent reason for abdominal surgery. In this perspective, the reader will find supporting data and references for these assertions as well as predictions for the future.
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Affiliation(s)
- Jonathan R Swanson
- Division of Neonatology, University of Virginia Children's Hospital, Charlottesville, VA, USA.
| | - Amy Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
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8
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Kim YI, Joo JY, Jung YH, Choi CW, Kim BI, Yang HR. Differentiation of food protein-induced enterocolitis syndrome misleading to necrotizing enterocolitis. Ann Allergy Asthma Immunol 2021; 128:193-198. [PMID: 34626783 DOI: 10.1016/j.anai.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/10/2021] [Accepted: 09/30/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is a rare non-immunoglobulin E-mediated food allergy with necrotizing enterocolitis (NEC)-like symptoms which requires differential diagnosis as treatments differ. OBJECTIVE To evaluate the clinical, laboratory, and radiologic findings that differentiate FPIES from NEC in preterm and term infants. METHODS Clinical features, comorbidities, and laboratory and radiologic findings of neonates with presumed NEC were reviewed retrospectively and compared between FPIES and NEC in preterm and term infants who were admitted to the neonatal intensive care unit at Seoul National University Bundang Hospital between May 2003 and February 2020. RESULTS A total of 10 of 150 (6.7%) preterm and 17 of 38 (44.7%) term infants with presumed NEC were confirmed to have FPIES; the remainder had NEC by modified Bell's criteria. Demographics and comorbidities were similar between these groups. Symptoms such as hematochezia, shock, leukocytosis, peripheral eosinophilia, and feeding of extensively hydrolyzed milk formula or elemental formula after discharge were significantly different between the 2 groups in term infants (P <.05), but not in preterm infants. On abdominal ultrasonography, pneumatosis intestinalis was more common among preterm FPIES (44.4%) than NEC cases (21.6%) (P =.04). Among the preterm infants, 4 FPIES (40%) and 25 NEC (17.9%) cases required surgery (P =.10). CONCLUSION Differentiating FPIES in neonates suspected of having NEC is important as dietary elimination of the triggering milk protein can be recommended instead of prolonged fasting and antibiotic treatment, which are indicated for NEC, in both term and preterm infants.
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Affiliation(s)
- You Ie Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung Yeon Joo
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Beyoung Il Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
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9
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Kinstlinger N, Fink A, Gordon S, Levin TL, Friedmann P, Nafday S, Statter M, Borenstein SH. Is necrotizing enterocolitis the same disease in term and preterm infants? J Pediatr Surg 2021; 56:1370-1374. [PMID: 33526254 DOI: 10.1016/j.jpedsurg.2021.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/06/2020] [Accepted: 01/11/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Necrotizing enterocolitis predominantly affects preterm (PT) infants. The paucity of data regarding the clinical course in term infants makes it difficult to predict outcomes and counsel families. To identify predisposing factors and gain a better understanding of the clinical course of NEC in term infants, we reviewed our experience with term infants and compared it to outcomes in PT infants. METHODS We performed a 10 year retrospective review of all infants admitted to our NICU with Bell stage 2 NEC or greater. Infants < 37 weeks gestation were considered PT. Term and PT infant comorbidities, outcomes and intraoperative findings were compared. RESULTS Fifteen (12%) of 125 infants were term. Compared to PT infants, term infants were more likely to have congenital heart disease (33% term vs. 10% PT, p = 0.02) and develop NEC sooner (4 days in term vs. 17 days in PT, p < 0.001) but were less likely to require operative intervention (20% term vs. 38% PT; p = 0.17). There was no significant difference in Bell stage, survival and development of intestinal failure. NEC totalis occurred exclusively in PT infants. CONCLUSIONS NEC in term infants has unique clinical features that distinguishes it from NEC in PT infants.
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Affiliation(s)
- Noah Kinstlinger
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Adam Fink
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Sharon Gordon
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Terry L Levin
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Patricia Friedmann
- Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA
| | - Suhas Nafday
- Division of Neonatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Mindy Statter
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA; Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA
| | - Steven H Borenstein
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA; Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA.
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10
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Donà D, Gastaldi A, Barbieri E, Bonadies L, Aluvaala J, English M. Empirical Antimicrobial Therapy of Neonates with Necrotizing Enterocolitis: A Systematic Review. Am J Perinatol 2021; 40:646-656. [PMID: 34126646 PMCID: PMC7614399 DOI: 10.1055/s-0041-1730364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal tract characterized by ischemic necrosis of the intestinal mucosa, mostly affecting premature neonates. Management of NEC includes medical care and surgical approaches, with supportive care and empirical antibiotic therapy recommended to avoid any disease progression. However, there is still no clear evidence-based consensus on empiric antibiotic strategies or surgical timing. This study was aimed to review the available evidence on the effectiveness and safety of different antibiotic regimens for NEC. STUDY DESIGN MEDLINE, EMBASE, Cochrane CENTRAL, and CINAHL databases were systematically searched through May 31, 2020. Randomized controlled trials (RCTs) and nonrandomized interventions reporting data on predefined outcomes related to NEC treatments were included. Clinical trials were assessed using the criteria and standard methods of the Cochrane risk of bias tool for randomized trials, while the risk of bias in nonrandomized studies of interventions was evaluated using the ROBINS-I tool. The certainty in evidence of each outcome's effects was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Five studies were included in this review, two RCTs and three observational studies, for a total amount of 3,161 patients. One RCT compared the outcomes of parenteral (ampicillin plus gentamicin) and oral (gentamicin) treatment with parenteral only. Three studies (one RCT and two observational) evaluated adding anaerobic coverage to different parenteral regimens. The last observational study compared two different parenteral antibiotic combinations (ampicillin and gentamicin vs. cefotaxime and vancomycin). CONCLUSION No antimicrobial regimen has been shown to be superior to ampicillin and gentamicin in decreasing mortality and preventing clinical deterioration in NEC. The use of additional antibiotics providing anaerobic coverage, typically metronidazole, or use of other broad-spectrum regimens as first-line empiric therapy is not supported by the very limited current evidence. Well-conducted, appropriately sized comparative trials are needed to make evidence-based recommendations. KEY POINTS · Ampicillin and gentamicin are effective in decreasing mortality and preventing clinical deterioration in NEC.. · Metronidazole could be added in patients with surgical NEC.. · No study with high-quality evidence was found..
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Affiliation(s)
- Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Andrea Gastaldi
- Department of Pediatrics, Woman and Child Hospital, University of Verona, Verona, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, United Kingdom
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11
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Watson SN, McElroy SJ. Potential Prenatal Origins of Necrotizing Enterocolitis. Gastroenterol Clin North Am 2021; 50:431-444. [PMID: 34024450 DOI: 10.1016/j.gtc.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Necrotizing enterocolitis is a serious and yet incompletely understood gastrointestinal disease of infancy that predominately impacts premature neonates. Prevention is a key strategy for the management of necrotizing enterocolitis. Although postnatal risk factors have been the focus of prevention efforts, obstetric complications, including intrauterine inflammation and infection, growth restriction, preeclampsia, and prenatal medications, have been associated with an increased risk of necrotizing enterocolitis. This article reviews the evidence behind the prenatal risk factors for necrotizing enterocolitis, and discusses how these risk factors may elucidate the pathogenesis of necrotizing enterocolitis and provide insight into prevention and treatment.
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Affiliation(s)
- Sarah N Watson
- Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242-1080, USA
| | - Steven J McElroy
- Stead Family Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242-1080, USA; Department of Microbiology and Immunology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242-1080, USA.
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12
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Abstract
Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.
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Affiliation(s)
- Jennifer Duchon
- Division of Newborn Medicine, Jack and Lucy Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1000 10th Avenue, New York, NY 10019, USA
| | - Maria E Barbian
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA
| | - Patricia W Denning
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Emory University Hospital Midtown, 550 Peachtree Street, 3rd Floor MOT, Atlanta, GA 30308, USA.
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Yang HB, Min JY, Byun J, Ko D, Kim HY, Min KB, Jung SE. Incidence of necrotizing enterocolitis in South Korea from 2007 to 2017. J Perinatol 2021; 41:1092-1099. [PMID: 33864007 DOI: 10.1038/s41372-021-01053-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 11/22/2020] [Accepted: 03/29/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the trends of the incidence of and mortality from necrotizing enterocolitis (NEC) in South Korea. METHODS Claim data were extracted with diagnosis code, including all stage of NEC. Kaplan-Meier curves for cumulative mortality rates are presented by birth weight (Bwt) and gestational age (GA). RESULT The total number of NEC cases was 5840. The ratio of males to females was 1.2:1. There were 11.9 cases per 10,000 births. There were approximately 10 cases per 1000 preterm births and 50 per 1000 very preterm births. The mortality of patients born under 37 weeks decreased from 38.7% in 2007 to 20.9% in 2017. Male sex, lower GA, and lower Bwt were risk factors for mortality. CONCLUSIONS NEC incidence and mortality have been decreasing over time in South Korea. Male sex, lower GA, and Bwt were risk factors for mortality.
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Affiliation(s)
- Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin-Young Min
- Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Jeik Byun
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, College of Medicine, Seoul National University, Seoul, Korea.
| | - Kyoung-Bok Min
- Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, Korea.
| | - Sung Eun Jung
- Department of Pediatric Surgery, College of Medicine, Seoul National University, Seoul, Korea
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Andrews L, Davies TH, Haas J, Loudin S, Heyward A, Werthammer J. Necrotizing enterocolitis and its association with the neonatal abstinence syndrome. J Neonatal Perinatal Med 2021; 13:81-85. [PMID: 32280068 PMCID: PMC7242835 DOI: 10.3233/npm-180154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE: The purpose of this study was to describe an identified association between necrotizing enterocolitis (NEC) and prenatal opioid exposure with neonatal abstinence syndrome (NAS) in late preterm and full-term neonates. STUDY DESIGN: In this single-center retrospective cohort study, we analyzed inborn neonates with the diagnosis of NEC discharged from 2012 through 2017. We compared infants with NEC > 35 weeks’ gestation to those with NEC<35 weeks’ gestation. We compared gestational age, birth weight, age of onset of symptoms, and incidence of prenatal drug exposure between groups. Significance was determined using Mann-Whitney and Fisher’s exact tests. RESULTS: Over the study period, 23 infants were identified with NEC, 9 (39%) were babies > 35 weeks at birth and 14 (61%) < 35 weeks. Those > 35 weeks had a higher birth weight, earlier onset of symptoms, and a higher percentage of prenatal exposure to opioids compared to those < 35 weeks’ gestation. We further described seven infants with late gestational age onset NEC associated with prenatal opioid exposure. CONCLUSIONS: In this cohort of infants with NEC discharged over a 6 year period we found a higher than expected percentage of infants born at a later gestational age. We speculate that prenatal opioid exposure might be a risk factor for NEC in neonates born at > 35 weeks.
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Affiliation(s)
- L Andrews
- Department of Family and Community Health at Joan C Edwards School of Medicine at Marshall University, Huntington WV, USA
| | - T H Davies
- Department of Family and Community Health at Joan C Edwards School of Medicine at Marshall University, Huntington WV, USA
| | - J Haas
- Hoops Family Children's Hospital at Cabell Huntington Hospital, Huntington, WV, USA
| | - S Loudin
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - A Heyward
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - J Werthammer
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
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15
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Young L, McGuire W. Immunologic Properties of Human Milk and Clinical Implications in the Neonatal Population. Neoreviews 2020; 21:e809-e816. [PMID: 33262207 DOI: 10.1542/neo.21-12-e809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Human milk contains various bioactive substances including hormones, immunoglobulins, enzymes, and growth factors in addition to its macro- and micronutrients. It has been suggested that human milk is a vehicle of communication between the maternal and infant immune systems, providing passive protection as well as direct active immunomodulation. Human milk protects newborns against pathogens by acting directly on multiple physiologic systems. Bioactive and immunologic factors regulate the infant's immune, metabolic, and microbiome systems. Breastfeeding protects infants in all socioeconomic groups, showing a pattern of protective dose/duration-response effects. This review summarizes the immune components and immunologic properties of human milk and provides an update of their potential implications in the neonatal population.
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Affiliation(s)
- Lauren Young
- Neonatal Medicine, Trevor Mann Baby Unit, Brighton and Sussex University Hospitals, Brighton, UK
| | - William McGuire
- Centre for Reviews and Dissemination and Hull York Medical School, University of York, York, UK
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16
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Mecarini F, Comitini F, Bardanzellu F, Neroni P, Fanos V. Neonatal supraventricular tachycardia and necrotizing enterocolitis: case report and literature review. Ital J Pediatr 2020; 46:117. [PMID: 32843076 PMCID: PMC7448440 DOI: 10.1186/s13052-020-00876-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/28/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and supraventricular tachycardia (SVT) are serious emergencies in the neonatal period. Although these conditions are recognized as distinct pathologies, literature reports suggest that recurrent episodes of SVT may predispose patients to NEC via disturbances in mesenteric blood flow and a decrease in tissue perfusion. CASE PRESENTATION We present a case of a preterm infant affected by recurrent episodes of SVT who developed the initial stage of NEC on the 17th day of life. Moreover, a detailed description of all the cases described in the literature is reported. MATERIALS AND METHODS An integrative review of the updated literature in the Medline database and PubMed and scientific books and articles was conducted. The research from October 2019 to December 2019 was searched for with MeSH and free terms (necrotizing enterocolitis, supraventricular tachycardia) and was linked by Boolean operators. CONCLUSIONS SVT can be considered a risk factor for the development of NEC. Therefore, clinicians should have a high level of suspicion for NEC in infants affected by SVT. This article is the first structured literature review analysing the association between SVT and NEC.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/therapy
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/therapy
- Male
- Tachycardia, Supraventricular/complications
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/therapy
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Affiliation(s)
- Federico Mecarini
- Neonatal Intensive Care Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
| | - Federica Comitini
- Neonatal Intensive Care Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Flaminia Bardanzellu
- Neonatal Intensive Care Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Paola Neroni
- Neonatal Intensive Care Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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17
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Rose HS, Monroe AK, Titus MO, Kane ID. Abdominal Distention and Emesis in a Term Neonate. J Emerg Med 2020; 58:e255-e258. [PMID: 32241709 DOI: 10.1016/j.jemermed.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/28/2020] [Accepted: 02/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a gastrointestinal emergency characterized by ischemic necrosis of the intestinal mucosa, leading to bacterial translocation and pneumatosis of the bowel wall. Although there are numerous studies on clinical presentations of preterm NEC, approximately 10-15% of cases occur in full-term neonates. Nearly 10% of all infants with NEC will develop a rapidly progressive and fatal form of the disease called NEC totalis. CASE REPORT A 24-day-old term male infant presented to the Emergency Department (ED) with emesis. The infant was ill-appearing with a tense abdomen and had significant tachycardia and hypotension. The patient was immediately volume resuscitated and started on empiric antibiotics. Initial radiographs revealed no evidence of bowel obstruction or pneumatosis. Pediatric Surgery was consulted, and upper gastrointestinal and abdominal computed tomography scans were obtained, which were nondiagnostic. The patient was taken to the operating room for an exploratory laparotomy after continued clinical deterioration and was diagnosed with NEC totalis and passed away within 6 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates an uncommon presentation of NEC in an otherwise healthy term neonate without any known risk factors. The diagnosis of NEC is challenging because imaging studies may be inconclusive, particularly early in the clinical course. Regardless of the etiology, all infants who present to the ED with signs and symptoms of severe gastrointestinal distress should be treated with basic emergency care, including rapid fluid resuscitation, empiric antibiotics, bowel decompression, and early surgical consultation.
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Affiliation(s)
- Holly S Rose
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Alexandra K Monroe
- Department of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - M Olivia Titus
- Department of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Ian D Kane
- Department of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
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18
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Rabon L, McGreevy JF. Respiratory Distress and Abdominal Distension in an 8-Month-Old. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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19
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Kaban RK, Wardhana, Hegar B, Rohsiswatmo R, Handryastuti S, Amelia N, Muktiarti D, Indrio F, Vandenplas Y. Lactobacillus reuteri DSM 17938 Improves Feeding Intolerance in Preterm Infants. Pediatr Gastroenterol Hepatol Nutr 2019; 22:545-553. [PMID: 31777720 PMCID: PMC6856506 DOI: 10.5223/pghn.2019.22.6.545] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 06/15/2019] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Feeding tolerance is extremely important in preterm infants. This study aimed to evaluate whether preterm infants receiving Lactobacillus reuteri DSM 17938 would develop fewer symptoms of feeding intolerance. Secondary outcomes were duration of parenteral nutrition, time to reach full feeding, length of hospital stay, sepsis, necrotizing enterocolitis (NEC), diarrhea, and mortality. METHODS This double-blind randomized controlled trial of L. reuteri DSM 17938 versus placebo included 94 neonates with a gestational age of 28-34 weeks and birth weight of 1,000-1,800 g. RESULTS Feeding intolerance (vomiting and/or distension) was less common in the probiotic group than in the placebo group (8.5% vs. 25.5%; relative risk, 0.33; 95% confidence interval, 0.12-0.96; p=0.03). No significant intergroup differences were found in proven sepsis, time to reach full feeding, length of hospital stay, or diarrhea. The prevalence of NEC (stages 2 and 3) was 6.4% in the placebo group vs. 0% in the probiotic group (relative risk, 1.07; 95% confidence interval, 0.99-1.15; p=0.24). Mortality rates were 2.1% in the probiotic group and 8.5% in the placebo group, p=0.36). CONCLUSION The administration of L. reuteri DSM 17938 to preterm infants was safe and significantly reduced feeding intolerance. No significant differences were found in any other secondary outcomes.
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Affiliation(s)
- Risma K. Kaban
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Wardhana
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Badriul Hegar
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rinawati Rohsiswatmo
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Setyo Handryastuti
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Novie Amelia
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Dina Muktiarti
- Department of Pediatric Health, Faculty of Medicine, Universitas Indonesia–Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Flavia Indrio
- Department of Paediatrics, University of Bari, Bari, Italy
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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20
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Bubberman JM, van Zoonen A, Bruggink JLM, van der Heide M, Berger RMF, Bos AF, Kooi EMW, Hulscher JBF. Necrotizing Enterocolitis Associated with Congenital Heart Disease: a Different Entity? J Pediatr Surg 2019; 54:1755-1760. [PMID: 30635129 DOI: 10.1016/j.jpedsurg.2018.11.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/24/2018] [Accepted: 11/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) predominantly occurs in preterm infants (PT-NEC). In term neonates, NEC occurs more frequently when a congenital heart disease is present (CHDNEC). Our aim was to evaluate differences and similarities in disease characteristics of PT-NEC versus CHD-NEC. METHODS In this retrospective case-control study we identified all CHD infants who developed NEC Bell's stage ≥2 in our center from 2004 to 2014. We randomly selected (1:2 ratio) PT-NEC infants from the same period. Biochemical and clinical variables were retrieved from patient files. RESULTS We found 18 CHD-NEC infants and selected 36 PT-NEC infants (gestational age 28.3 [25-35.6] weeks vs. 38.6 [31.7-40.7] weeks). Postnatal age at onset was significantly lower in CHD-NEC patients (4 [2-24] vs. 11 [4-41] days, p < 0.001). Lowest pH levels were lower (7.21 [7.01-7.47] vs. 7.27 [6.68-7.39], p = 0.02), and highest CRP levels were higher (112.5 mg/L [5.0-425.0] vs. 66.0 [5.2-189.0], p = 0.05) in PT-NEC vs. CHD-NEC. Anatomic localisation of the disease differed: the colon was significantly more often involved in CHD-NEC versus PT-NEC (86% vs. 33%, p = 0.03). Mortality caused by NEC was not different (22% vs. 11%, p = 0.47). CONCLUSION While outcome of NEC in both groups is similar, the predominant NEC localisation differed between CHD-NEC and PT-NEC patients. This suggests that both variants of the disease have a different underlying pathophysiological mechanism that predisposes different intestinal regions to develop NEC. TYPE OF STUDY Retrospective Case-Control Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- J M Bubberman
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - A van Zoonen
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - J L M Bruggink
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - M van der Heide
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - R M F Berger
- University Medical Center Groningen, Department of Paediatrics, Division of Paediatric Cardiology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - A F Bos
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - E M W Kooi
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - J B F Hulscher
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
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21
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McClelland K, Ibrahim J. Case 3: Abdominal Distention and Bloody Stools in a 2-week-old Term Neonate. Neoreviews 2019; 20:e415-e418. [PMID: 31261109 DOI: 10.1542/neo.20-7-e415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Katybeth McClelland
- Division of Newborn Medicine, Children's Hospital of Pittsburgh/UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - John Ibrahim
- Division of Newborn Medicine, Children's Hospital of Pittsburgh/UPMC Magee-Womens Hospital, Pittsburgh, PA
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22
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Trivić I, Mlakar AS, Hojsak I. The Role of Probiotics in the Prevention of Necrotizing Enterocolitis. Curr Pediatr Rev 2019; 15:88-91. [PMID: 30582482 DOI: 10.2174/1573396315666181224123223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/10/2018] [Accepted: 12/14/2018] [Indexed: 01/18/2023]
Abstract
Necrotizing enterocolitis (NEC) is a frequent and severe life-threatening disease affecting the gastrointestinal tract of preterm infants. Given that NEC occurs in a well-defined population of patients, there might be a considerable benefit in identifying specific pharmacological and nutritional preventive strategies, that could reduce the incidence of NEC. Amongst nutritional strategies emphasis has been put on the use of probiotics. Therefore, the aim of this review is to summarize currently available evidence on the role of probiotics in general, as well as the role of specific probiotic strains or their combinations, in the prevention of NEC.
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Affiliation(s)
| | - Ana Savić Mlakar
- Center for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Zagreb, Croatia
| | - Iva Hojsak
- Children's Hospital Zagreb, Zagreb, Croatia.,University of Zagreb, School of Medicine, Zagreb, Croatia.,University J.J. Strossmayer, School of Medicine Osijek, Osijek, Croatia
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23
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Huff C, Mastropietro CW, Riley C, Byrnes J, Kwiatkowski DM, Ellis M, Schuette J, Justice L. Comprehensive Management Considerations of Select Noncardiac Organ Systems in the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2018; 9:685-695. [PMID: 30322370 DOI: 10.1177/2150135118779072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As the acuity and complexity of pediatric patients with congenital cardiac disease have increased, there are many noncardiac issues that may be present in these patients. These noncardiac problems may affect clinical outcomes in the cardiac intensive care unit and must be recognized and managed. The Pediatric Cardiac Intensive Care Society sought to provide an expert review of some of the most common challenges of the respiratory, gastrointestinal, hematological, renal, and endocrine systems in pediatric cardiac patients. This review provides a brief overview of literature available and common practices.
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Affiliation(s)
- Christin Huff
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher W Mastropietro
- 2 Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Jonathan Byrnes
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Misty Ellis
- 5 Department of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | | | - Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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24
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Nair J, Longendyke R, Lakshminrusimha S. Necrotizing Enterocolitis in Moderate Preterm Infants. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4126245. [PMID: 30406135 PMCID: PMC6199891 DOI: 10.1155/2018/4126245] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/18/2018] [Indexed: 11/21/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating morbidity usually seen in preterm infants, with extremely preterm neonates (EPT ≤28 weeks) considered at highest risk. Moderately preterm infants (MPT 28-34 weeks) constitute a large percentage of NICU admissions. In our retrospective data analysis of NEC in a single regional perinatal center, NEC was observed in 10% of extremely EPT and 7% of MPT, but only 0.7% of late-preterm/term admissions. There was an inverse relationship between postnatal age at onset of NEC and gestational age at birth. Among MPT infants with NEC, maternal hypertensive disorders (29%) and small for gestational age (SGA-15%) were more common than in EPT infants (11.6 and 4.6%, resp.). Congenital gastrointestinal anomalies were common among late preterm/term infants with NEC. SGA MPT infants born to mothers with hypertensive disorders are particularly at risk and should be closely monitored for signs of NEC. Identifying risk factors specific to each gestational age may help clinicians to tailor interventions to prevent NEC.
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Affiliation(s)
- Jayasree Nair
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
| | - Rachel Longendyke
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
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25
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Calprotectin and necrotizing enterocolitis: it's not the assay, it's the definition. J Perinatol 2018; 38:1285-1286. [PMID: 30108341 DOI: 10.1038/s41372-018-0201-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/16/2018] [Indexed: 11/09/2022]
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26
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Esdal HCD, Ghbeis MB, Saltzman DA, Hess D, Hume JR, Reed RC, Berry SA, Hoggard E, Hirsch B, Baughn LB, Schimmenti LA. Necrotizing Enterocolitis in Two Siblings and an Unrelated Infant with Overlapping Chromosome 6q25 Deletions. Mol Syndromol 2018; 9:141-148. [PMID: 29928179 DOI: 10.1159/000488817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 11/19/2022] Open
Abstract
The pathogenesis of necrotizing enterocolitis (NEC) remains poorly understood but is thought to be multifactorial. There are no specific recurring chromosomal abnormalities previously associated with NEC. We report 3 cases of intestinal necrosis associated with large chromosome 6 deletions. The first patient was found to have a 7.9-Mb deletion of chromosome 6 encompassing over 40 genes, arr[GRCh37] 6q25.3q26(155699183_163554531)×1. The second patient had a 19.5-Mb deletion of chromosome 6 generated by an unbalanced translocation with chromosome 18, 46,XY,der(6)t (6;18)(q25.1;p11.23), arr[GRCh37] 6q25.1q27(151639526_ 171115067)×1, 18p11.32p11.23(131700_7694199)×3, which included the whole 7.9-Mb region deleted in the first patient. The third patient was the younger sibling of the second patient with an identical derivative chromosome 6. The shared abnormal chromosome 6 region includes multiple genes of interest, particularly EZR. Mouse models have demonstrated that Ezr is expressed in microvillar epithelium and helps regulate cell-cell adhesion in the gut. We hypothesize that deletion of this shared region of 6q leads to gastrointestinal vulnerability which may predispose patients to intestinal necrosis.
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Affiliation(s)
- Hannah C D Esdal
- Department of Pediatrics, University of Minnesota, Minneapolis, USA
| | - Muhammad B Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Daniel A Saltzman
- Department of Pediatric Surgery, Divisions of, University of Minnesota Masonic Children's Hospital, Minneapolis, USA
| | - Donavon Hess
- Department of Pediatric Surgery, Divisions of, University of Minnesota Masonic Children's Hospital, Minneapolis, USA
| | - Janet R Hume
- Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, USA
| | - Robyn C Reed
- Department of Pathology, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Susan A Berry
- Genetics and Metabolism, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, USA
| | - Eric Hoggard
- Division of Pediatric Radiology, Department of Radiology, University of Minnesota Masonic Children's Hospital, Minneapolis, USA
| | - Betsy Hirsch
- Division of Molecular Pathology and Genomics, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Linda B Baughn
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A Schimmenti
- Department of Otorhinolaryngology and Clinical Genomics, Mayo Clinic, Rochester, MN, USA
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27
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Gephart SM, Gordon PV, Penn AH, Gregory KE, Swanson JR, Maheshwari A, Sylvester K. Changing the paradigm of defining, detecting, and diagnosing NEC: Perspectives on Bell's stages and biomarkers for NEC. Semin Pediatr Surg 2018; 27:3-10. [PMID: 29275814 DOI: 10.1053/j.sempedsurg.2017.11.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Better means to diagnose and define necrotizing enterocolitis are needed to guide clinical practice and research. Adequacy of Bell's staging system for clinical practice and clarity of cases used in NEC clinical datasets has been a topic of controversy for some time. This article provides reasons why a better global definition for NEC is needed and offers a simple alternative bedside definition for preterm NEC called the "Two out of Three" rule. Some argue that biomarkers may fill knowledge gaps and provide greater precision in defining relevant features of a clinical disease like NEC. NEC biomarkers include markers of inflammation, intestinal dysfunction, hematologic changes, and clinical features. Development and reporting of NEC biomarkers should be guided by the FDA's BEST Consensus resource, "Biomarkers, EndpointS, & other Tools" and consistently report metrics so that studies can be compared and results pooled. Current practice in the NICU would be enhanced by clinical tools that effectively inform the clinical team that a baby is at increasing risk of NEC. Ideally, these tools will incorporate both clinical information about the baby as well as molecular signals that are indicative of NEC. While meaningful biomarkers for NEC and clinical tools exist, translation into practice is mediocre.
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Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science, The University of Arizona College of Nursing, PO Box 210203, Tucson, Arizona 85721.
| | - Phillip V Gordon
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, Florida; Sacred Heart Children's Hospital, Pensacola, Florida
| | | | - Katherine E Gregory
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Nursing, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan R Swanson
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Akhil Maheshwari
- Department of Pediatrics, Molecular Medicine and Public Health, University of South Florida, Tampa, Florida
| | - Karl Sylvester
- Department of Surgery and Pediatrics, Stanford University School of Medicine, Palo Alto, California; Department of Research, Stanford University School of Medicine, Palo Alto, California; Fetal and Pregnancy Health, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Jung K, Koh I, Kim JH, Cheong HS, Park T, Nam SH, Jung SM, Sio CA, Kim SY, Jung E, Lee B, Kim HR, Shin E, Jung SE, Choi CW, Kim BI, Jung E, Shin HD. RNA-Seq for Gene Expression Profiling of Human Necrotizing Enterocolitis: a Pilot Study. J Korean Med Sci 2017; 32:817-824. [PMID: 28378556 PMCID: PMC5383615 DOI: 10.3346/jkms.2017.32.5.817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/27/2017] [Indexed: 12/11/2022] Open
Abstract
Necrotizing enterocolitis (NEC) characterized by inflammatory intestinal necrosis is a major cause of mortality and morbidity in newborns. Deep RNA sequencing (RNA-Seq) has recently emerged as a powerful technology enabling better quantification of gene expression than microarrays with a lower background signal. A total of 10 transcriptomes from 5 pairs of NEC lesions and adjacent normal tissues obtained from preterm infants with NEC were analyzed. As a result, a total of 65 genes (57 down-regulated and 8 up-regulated) revealed significantly different expression levels in the NEC lesion compared to the adjacent normal region, based on a significance at fold change ≥ 1.5 and P ≤ 0.05. The most significant gene, DPF3 (P < 0.001), has recently been reported to have differential expressions in colon segments. Our gene ontology analysis between NEC lesion and adjacent normal tissues showed that down-regulated genes were included in nervous system development with the most significance (P = 9.3 × 10⁻⁷; P(corr) = 0.0003). In further pathway analysis using Pathway Express based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, genes involved in thyroid cancer and axon guidance were predicted to be associated with different expression (P(corr) = 0.008 and 0.020, respectively). Although further replications using a larger sample size and functional evaluations are needed, our results suggest that altered gene expression and the genes' involved functional pathways and categories may provide insight into NEC development and aid in future research.
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Affiliation(s)
- Kyuwhan Jung
- Department of Surgery, Jeju National University Hospital, Jeju, Korea
| | - Insong Koh
- Department of Physiology, College of Medicine, Hanyang University, Seoul, Korea
| | - Jeong Hyun Kim
- Research Institute for Basic Science, Sogang University, Seoul, Korea
| | - Hyun Sub Cheong
- Department of Genetic Epidemiology, SNP Genetics, Inc., Seoul, Korea
| | - Taejin Park
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - So Hyun Nam
- Department of Surgery, Donga University Hospital, Busan, Korea
| | - Soo Min Jung
- Department of Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Cherry Ann Sio
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Su Yeong Kim
- Department of Surgery, Donga University Hospital, Busan, Korea
| | - Euiseok Jung
- Department of Neonatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byoungkook Lee
- Department of Neonatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Rim Kim
- Department of Neonatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Shin
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Eun Jung
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Chang Won Choi
- Department of Neonatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Beyong Il Kim
- Department of Neonatology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eunyoung Jung
- Department of Surgery, Gyemyoung University Dongsan Hospital, Daegu, Korea
| | - Hyoung Doo Shin
- Research Institute for Basic Science, Sogang University, Seoul, Korea
- Department of Life Science, Sogang University, Seoul, Korea.
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Li QY, An Y, Liu L, Wang XQ, Chen S, Wang ZL, Li LQ. Differences in the Clinical Characteristics of Early- and Late-Onset Necrotizing Enterocolitis in Full-Term Infants: A Retrospective Case-Control Study. Sci Rep 2017; 7:43042. [PMID: 28211488 PMCID: PMC5314368 DOI: 10.1038/srep43042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
Information regarding the influence of age at onset on prognosis in full-term infants with necrotizing enterocolitis (NEC) is limited, and identifying differences between the clinical characteristics of early-onset NEC (EO-NEC) and late-onset NEC (LO-NEC) may be helpful in the determination of effective management strategies. In the present study, the medical records of 253 full-term infants with NEC were reviewed, and the clinical characteristics of the EO-NEC group (n = 150) and the LO-NEC group (n = 103) were compared. Infants in the EO-NEC group were characterized by increased gestational age and higher rates of stage III NEC and peritonitis when compared with LO-NEC infants (P < 0.05). Mortality was significantly associated with stage III NEC, peritonitis, sepsis, respiratory failure and shock in univariate analysis (P < 0.05). In logistic regression analysis, peritonitis and renal failure were identified as independent risk factors for mortality in infants with EO-NEC, and peritonitis and respiratory failure were significant predictors of mortality in neonates with LO-NEC. Our finding indicated that the characteristics of the severe medical conditions identified in infants with EO-NEC were distinct from those observed in infants with LO-NEC. Peritonitis and kidney failure and peritonitis and respiratory failure were identified as risk factors for mortality in EO-NEC and LO-NEC infants, respectively.
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Affiliation(s)
- Qiu-Yu Li
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Yao An
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Li Liu
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Xue-Qiu Wang
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Shi Chen
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Zheng-Li Wang
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Lu-Quan Li
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
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Zubarioglu U, Uslu S, Bulbul A. New Frontiers of Necrotizing Enterocolitis: From Pathophysiology to Treatment. Health (London) 2017. [DOI: 10.4236/health.2017.91008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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31
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Niño DF, Sodhi CP, Hackam DJ. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nat Rev Gastroenterol Hepatol 2016; 13:590-600. [PMID: 27534694 PMCID: PMC5124124 DOI: 10.1038/nrgastro.2016.119] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most frequent and lethal disease of the gastrointestinal tract of preterm infants. At present, NEC is thought to develop in the premature host in the setting of bacterial colonization, often after administration of non-breast milk feeds, and disease onset is thought to be due in part to a baseline increased reactivity of the premature intestinal mucosa to microbial ligands as compared with the full-term intestinal mucosa. The increased reactivity leads to mucosal destruction and impaired mesenteric perfusion and partly reflects an increased expression of the bacterial receptor Toll-like receptor 4 (TLR4) in the premature gut, as well as other factors that predispose the intestine to a hyper-reactive state in response to colonizing microorganisms. The increased expression of TLR4 in the premature gut reflects a surprising role for this molecule in the regulation of normal intestinal development through its effects on the Notch signalling pathway. This Review will examine the current approach to the diagnosis and treatment of NEC, provide an overview of our current knowledge regarding its molecular underpinnings and highlight advances made within the past decade towards the development of specific preventive and treatment strategies for this devastating disease.
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MESH Headings
- Animals
- Biological Factors/therapeutic use
- Biomarkers/metabolism
- Breast Feeding
- Disease Models, Animal
- Disease Susceptibility
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/prevention & control
- Gastrointestinal Microbiome/physiology
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/therapy
- Probiotics/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Diego F Niño
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - David J Hackam
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
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Buchmann EJ, Stones W, Thomas N. Preventing deaths from complications of labour and delivery. Best Pract Res Clin Obstet Gynaecol 2016; 36:103-115. [PMID: 27427491 DOI: 10.1016/j.bpobgyn.2016.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 11/17/2022]
Abstract
The process of labour and delivery remains an unnecessary and preventable cause of death of women and babies around the world. Although the rates of maternal and perinatal death are declining, there are large disparities between rich and poor countries, and sub-Saharan Africa has not seen the scale of decline as seen elsewhere. In many areas, maternity services remain sparse and under-equipped, with insufficient and poorly trained staff. Priorities for reducing the mortality burden are provision of safe caesarean section, prevention of sepsis and appropriate care of women in labour in line with the current best practices, appropriately and affordably delivered. A concern is that large-scale recourse to caesarean delivery has its own dangers and may present new dominant causes for maternal mortality. An area of current neglect is newborn care. However, innovative training methods and appropriate technologies offer opportunities for affordable and effective newborn resuscitation and follow-up management in low-income settings.
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Affiliation(s)
- Eckhart J Buchmann
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, PO Bertsham 2013, Johannesburg, South Africa.
| | - William Stones
- School of Medicine, University of St Andrews and College of Medicine, University of Malawi, Fife KY16 9JT, UK.
| | - Niranjan Thomas
- Department of Neonatology, Christian Medical College, Vellore 632004, India.
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Zhang Y, Ma JK, Wei H, Li XW, Li LQ, Yu JL. Predictive scores for mortality in full-term infants with necrotizing enterocolitis: experience of a tertiary hospital in Southwest China. World J Pediatr 2016; 12:202-8. [PMID: 26684312 DOI: 10.1007/s12519-015-0063-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 10/23/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although many risk factors for mortality of necrotizing enterocolitis (NEC) were investigated, most of them were obtained from preterm infants, and few works focused on the prognostic risk factors in fullterm infants. This study aimed to identify risk factors and develop a prediction score model for mortality in fullterm neonates with NEC. METHODS The risk factors were analyzed retrospectively by bivariate and multivariate logistic regression analysis in 153 full-term neonates with NEC, who were hospitalized in Children's Hospital of Chongqing Medical University from 2000 to 2013. A prediction score model was developed according to the regression coefficients of risk factors. RESULTS The mortality of the infants was 19.6% (30/153). The non-survivors had a younger age of diagnosis and advanced stage of NEC (P<0.05). They had a higher prevalence of respiratory failure, intestinal perforation, peritonitis and other complications, compared with the survivors (P<0.05). On the day of diagnosis, the nonsurvivors were more likely to have abnormal laboratory indicators than survivors (P<0.05). Age at diagnosis [odds ratio (OR)=0.91, 95% confidence interval (CI)=0.836-0.99], respiratory failure (OR=2.76, 95% CI=1.10-6.92), and peritonitis (OR=26.36, 95% CI=7.52-173.92) had significant independent contributions to death. A score model predicting death was developed, and the area under the receiver operating characteristic curve was 0.869 (95% CI=0.803-0.935). All infants with scores ≥8 died. CONCLUSION Younger age at diagnosis, peritonitis, and respiratory failure might be risk factors for the mortality of full-term infants with NEC. Infants with a predictive score of 8 were at high risk for death.
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Affiliation(s)
- Yu Zhang
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Ji-Kun Ma
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Hong Wei
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Xiao-Wen Li
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Lu-Quan Li
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China.
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, 400014, China.
| | - Jia-Lin Yu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing and Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
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O'Neil AM, Homme JL. Evaluation of Hematochezia in a Two-Day-Old Infant. J Emerg Med 2015; 50:41-3. [PMID: 26603360 DOI: 10.1016/j.jemermed.2015.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/17/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hematochezia in the pediatric population, particularly infants, has a wide differential diagnosis ranging from benign to life-threatening causes. Obtaining a thorough history and identifying risk factors for more ominous disease is vital during the emergency department (ED) evaluation. CASE REPORT The patient is a 2-day-old female who presented to the ED with 8-10 episodes of bright red blood in her stools. She was otherwise asymptomatic, with an uncomplicated pregnancy and delivery. Her history was significant for a sibling who recently tested positive for Escherichia coli O157:H7 in his stool and a family history of lactose intolerance. She was exclusively formula fed. An abdominal plain film was obtained and was normal. Milk protein enterocolitis was suspected and she was transitioned to hydrolyzed formula with resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As emergency physicians, we need to be aware of the life-threatening conditions that are associated with hematochezia, such as necrotizing enterocolitis, and act quickly. However, many patients will have benign conditions, and recognizing the key historical and diagnostic pieces of the infant's presentation will prevent unnecessary evaluations and consultations.
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Affiliation(s)
- Amy M O'Neil
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - James L Homme
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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Jung K, Kim JH, Cheong HS, Shin E, Kim SH, Hwang JY, Lee E, Yoon MO, Kim SH, Sio CA, Shin HD, Jung SE. Gene expression profile of necrotizing enterocolitis model in neonatal mice. Int J Surg 2015; 23:28-34. [PMID: 26403067 DOI: 10.1016/j.ijsu.2015.09.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) characterized by intestinal necrosis is one of the most common gastrointestinal emergencies in newborns. The main purpose of this study was to evaluate the whole genome expression levels in a NEC mouse model controlled with breast milk. METHODS This study induced a NEC model in mice of gestational ages of 18-21 days by intensive hypoxic insult and permitted breast-feeding instead of formula feeding. After evaluating the NEC status in the small intestines of neonatal mice by histological examination, a genome-wide gene expression profile study was completed using microarray analysis. RESULTS A total of 72 genes (38 down-regulated and 34 up-regulated) were observed to have significantly different expression profiles in the NEC mouse model compared with the normal control animals, based on a significance at fold change ≥ 2 and P < 0.05. In particular, down-regulated Hist1h2aa and up-regulated Ube2i showed the most significant signals (P = 0.0008 for both genes). In an additional gene ontology analysis, the endopeptidase related categories (specifically, serine-type endopeptidase inhibitor activity, P = 8.95 × 10(-5); Pcorr = 0.008) appeared to affect NEC development in the mouse model. CONCLUSION Although replications and functional evaluations are needed, our results suggest that several genes may have different expression profiles in the NEC mouse model. In particular, endopeptidase related genes (which are also known to be relevant to NEC), as identified through gene ontology analysis, may represent attractive targets for future research.
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Affiliation(s)
- Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Jeong-Hyun Kim
- Research Institute for Basic Science, Sogang University, Seoul, 121-742, Republic of Korea
| | - Hyun Sub Cheong
- Department of Genetic Epidemiology, SNP Genetics, Inc., Seoul 153-803, Republic of Korea
| | - Eun Shin
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Seong-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Ji-Yeon Hwang
- Preclinical Experimental Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Eunyoung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Mi-Ok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Seong-Hee Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Cherry Ann Sio
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, 463-707, Republic of Korea
| | - Hyoung Doo Shin
- Research Institute for Basic Science, Sogang University, Seoul, 121-742, Republic of Korea; Department of Life Science, Sogang University, Seoul 121-742, Republic of Korea.
| | - Sung-Eun Jung
- Department of Surgery, Seoul National University Children's Hospital, Seoul 110-773, Republic of Korea.
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Patrick SW, Dudley J, Martin PR, Harrell FE, Warren MD, Hartmann KE, Ely EW, Grijalva CG, Cooper WO. Prescription opioid epidemic and infant outcomes. Pediatrics 2015; 135:842-50. [PMID: 25869370 PMCID: PMC4411781 DOI: 10.1542/peds.2014-3299] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS). METHODS We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics. RESULTS Of 112,029 pregnant women, 31,354 (28%) filled ≥ 1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]) were associated with greater risk of developing NAS. CONCLUSIONS Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS.
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Affiliation(s)
- Stephen W Patrick
- Departments of Pediatrics, Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee; Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy,
| | | | | | | | | | - Katherine E Hartmann
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Obstetrics and Gynecology, and
| | - E Wesley Ely
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Medicine, Vanderbilt University, Nashville, Tennessee; Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy, Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - William O Cooper
- Departments of Pediatrics, Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy
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Sharma D, Shastri S. Lactoferrin and neonatology – role in neonatal sepsis and necrotizing enterocolitis: present, past and future. J Matern Fetal Neonatal Med 2015; 29:763-70. [DOI: 10.3109/14767058.2015.1017463] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Müller B, Stahr N, Knirsch W, Hoigné I, Frey B. Bubbles in the heart as first sign of gastric pneumatosis. Eur J Pediatr 2014; 173:1587-9. [PMID: 23955485 DOI: 10.1007/s00431-013-2129-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/30/2013] [Indexed: 11/30/2022]
Abstract
UNLABELLED This case report describes a 5-week-old boy with an unusual presentation of gastric pneumatosis caused by suspected necrotizing enterocolitis (NEC) after cardiogenic shock. Postnatally, a pulmonary atresia with intact ventricular septum was supplied by a modified Blalock-Taussig shunt. On transthoracic echocardiography in week 5, primarily performed to rule out pericardial effusion, air bubbles have been apparent in the right atrium. Intracardiac air found on echocardiogram is generally associated with an indwelling venous catheter but-as exemplified by this case report-may also occur in the setting of NEC. An abdominal radiograph showed an isolated gastric pneumatosis, which is an unusual location of NEC. It is speculated that air moved through the connecting veins to the right atrium, the pneumatosis located in the gastric wall being a prerequisite to this pathophysiology. CONCLUSION The suspected NEC was located in the stomach enabling the intramural air to pass through connecting veins to the right atrium. The first specific sign of NEC in our case was air bubbles in the right atrium on echocardiography.
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Affiliation(s)
- Béatrice Müller
- Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland,
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Can a national dataset generate a nomogram for necrotizing enterocolitis onset? J Perinatol 2014; 34:732-5. [PMID: 25078862 DOI: 10.1038/jp.2014.137] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/27/2014] [Accepted: 06/09/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Mother's own milk and donor human milk use is increasing as a means of necrotizing enterocolitis (NEC) prevention. Early onset of enteral feeding has been associated with improvement of many outcomes but has not been shown to reduce the incidence of NEC. Better definition of the window of risk for NEC by gestational strata should improve resource management with respect to donor human milk and enhance our understanding of NEC timing and pathogenesis. Our objective was to establish a NEC dataset of sufficient size and quality, then build a generalizable model of NEC onset from the dataset across gestational strata. STUDY DESIGN We used de-identified data from the Pediatrix national dataset and filtered out all diagnostic confounders that could be identified by either specific diagnoses or logical exclusions (example dual diagnoses), with a specific focus on NEC and spontaneous intestinal perforation (SIP) as the outcomes of interest. The median day of onset was plotted against the gestational age for each of these diagnoses and analyzed for similarities and differences in the day of diagnosis. RESULT Onset time of medical NEC was inversely proportional to gestation in a linear relationship across all gestational ages. We found the medical NEC dataset displayed characteristics most consistent with a homogeneous disease entity, whereas there was a skew towards early presentation in the youngest gestation groups of surgical NEC (suggesting probable SIP contamination). CONCLUSION Our national dataset demonstrates that NEC onset occurs in an inverse stereotypic, linear relationship with gestational age at birth. Medical NEC is the most reliable sub-cohort for the purpose of determining the temporal window of NEC risk.
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Kasivajjula H, Maheshwari A. Pathophysiology and current management of necrotizing enterocolitis. Indian J Pediatr 2014; 81:489-97. [PMID: 24652270 DOI: 10.1007/s12098-014-1388-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 02/20/2014] [Indexed: 02/04/2023]
Abstract
Necrotizing enterocolitis (NEC), an inflammatory bowel necrosis of preterm infants, is the most common gastrointestinal emergency and a major cause of morbidity and mortality in these infants. In this article, the authors review the pathophysiology and clinical presentation of NEC and provide a critical appraisal of the evidence supporting various prophylactic and therapeutic strategies. A literature search was performed using the databases PubMed, EMBASE, and Scopus. Current pathophysiological models of NEC suggest that the disease occurs when mucosal injury in the preterm intestine results in translocation of luminal bacteria across the epithelial barrier, triggering an exaggerated and damaging local inflammatory response. Medical management of NEC is largely supportive and likely does not modify the etiopathogenesis of this disease. Antenatal steroids, human milk feedings, adoption of standardized feeding regimens, and probiotics hold promise for prevention of NEC. Future research should focus on early recognition that occurs well before the onset of intestinal necrosis, and prevention of this disease.
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Affiliation(s)
- Himabindu Kasivajjula
- Division of Neonatology and the Center for Neonatal and Pediatric Gastrointestinal Disease, Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
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Abstract
Necrotizing enterocolitis (NEC) continues to be the most severe gastrointestinal emergency facing the preterm neonate. The pathogenesis of NEC is still a complex and poorly understood process, but with increasing understanding of the role of enteral feeding, gut immunity and the altered gut microbiota, new opportunities to reduce overall NEC rates are now possible. Prevention strategies continue to lead as the most suitable approaches to reducing NEC, as early diagnosis and rapid effective treatment of NEC are still not optimal. Programmatic changes are equally important as subscribing to individual prevention strategies. The primary focus of this review is to summarize the best strategies we currently have to eliminate NEC within an institution.
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Kampanatkosol R, Thomson T, Habeeb O, Glynn L, Dechristopher PJ, Yong S, Jeske W, Maheshwari A, Muraskas J. The relationship between reticulated platelets, intestinal alkaline phosphatase, and necrotizing enterocolitis. J Pediatr Surg 2014; 49:273-6. [PMID: 24528965 PMCID: PMC4423723 DOI: 10.1016/j.jpedsurg.2013.11.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/10/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) affects up to 10% of extremely-low-birthweight infants, with a 30% mortality rate. Currently, no biomarker reliably facilitates early diagnosis. Since thrombocytopenia and bowel ischemia are consistent findings in advanced NEC, we prospectively investigated two potential biomarkers: reticulated platelets (RP) and intestinal alkaline phosphatase (iAP). METHODS Infants born ≤ 32 weeks and/or ≤ 1500 g were prospectively enrolled from 2009 to 2012. Starting within 72 hours of birth, 5 weekly whole blood specimens were collected to measure RP and serum iAP. Additional specimens were obtained at NEC onset (Bell stage II or III) and 24 hours later. Dichotomous cut-points were calculated for both biomarkers. Non-parametric (Mann-Whitney) and Chi-square tests were used to test differences between groups. Differences in Kaplan-Meier curves were examined by log-rank test. The Cox proportional hazards model estimated hazard ratios. RESULTS A total of 177 infants were enrolled in the study, 15 (8.5%) of which developed NEC (40% required surgery and 20% died). 14 (93%) NEC infants had "low" (≤ 2.3%) reticulated platelets, and 9 (60%) had "high" iAP (>0 U/L) in at least one sample before onset. Infants with "low" RP were significantly more likely to develop NEC [HR=11.0 (1.4-83); P=0.02]. Infants with "high" iAP were at increased risk for NEC, although not significant [HR=5.2 (0.7-42); P=0.12]. Median iAP levels were significantly higher at week 4 preceding the average time to NEC onset by one week (35.7 ± 17.3 days; P=0.02). CONCLUSION Decreased RP serves as a sensitive marker for NEC onset, thereby enabling early preventative strategies. iAP overexpression may signal NEC development.
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Affiliation(s)
| | | | - Omar Habeeb
- Hutt Valley District Health Board, Wellington, New Zealand
| | - Loretto Glynn
- Ann and Robert H. Lurie Children's Hospital at Cadence Health, Winfield, IL, USA
| | | | - Sherri Yong
- Loyola University Medical Center, Maywood, IL, USA
| | - Walter Jeske
- Loyola University Medical Center, Maywood, IL, USA
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