Reducing Incidence of Necrotizing Enterocolitis

Indications and successes of intestinal transplantation in children in the 21st century: A retrospective cohort study

AIMS

To report the results and successes of intestinal transplantation (ITx) in the most active European centres, to emphasize that, although it is a difficult procedure, it should remain a therapeutic option for children with total, definitive and complicated intestinal failure when intestinal rehabilitation fails.

METHODS

We retrospectively collected data about all patients less than 18 receiving an ITx from 2010 to 2022 in 8 centres, and outcomes in July 2022.

RESULTS

ITx was performed in 155 patients, median age 6.9 years, in 45% for short bowel syndromes, 22% congenital enteropathies, 25% motility disorders, and 15% re-transplantations. Indications were multiple in most patients, intestinal failure-associated liver disease in half. The graft was in 70% liver-containing. At last follow up 64% were alive, weaned from parenteral nutrition, for 7.9 years; 27% had died and the graft was removed in 8%, mostly early after ITx.

DISCUSSION

ITx, despite its difficulties, can give a future to children with complicated intestinal failure. It should be considered among the therapeutic options offered to patients with a predicted survival rate lower than that after ITx. Patients should be early discussed within multidisciplinary teams in ITx centres, to avoid severe complications impacting the results of ITx, or even to avoid ITx.

Necrotizing Enterocolitis in Very Low Birth Weight Neonates: A Natural History Study

OBJECTIVE

 We characterize the most recent natural history of necrotizing enterocolitis (NEC), as this is an essential first step in guiding the prevention and treatment of this disease in the present day.

STUDY DESIGN

 We performed a retrospective cohort study of neonates who were born at 23 to 29 weeks' gestation and birth weight <1,500 g who received care from the Pediatrix Medical Group between 2004 and 2019. We assessed the incidence of medical and surgical NEC and the patterns of initial antibiotic treatment to develop a contemporary cohort for further analysis. Among patients discharged between 2015 and 2019, we characterized the stage-specific risk factors for patients diagnosed with medical or surgical NEC, as well as patterns of disease onset, progression, biomarkers, and outcomes. We used the same approach to characterize patients diagnosed with suspected NEC.

RESULTS

 Among 34,032 patients in the contemporary cohort, 1,150 (3.4%) were diagnosed with medical NEC and 543 (1.6%) were diagnosed with surgical NEC. The temporal pattern of disease onset was different for medical and surgical NEC, with gestational age- and birth weight-specific risk disparities emerging earlier in surgical NEC. Thirty-day mortality was much greater among surgical NEC patients (medical NEC 16.4% vs. surgical NEC 43.0%), as were rates of various in-hospital and long-term outcomes. Suspected NEC was diagnosed in 1,256 (3.7%) patients, among whom risk factors and disease onset, progression, and outcomes closely resembled those of medical NEC.

CONCLUSION

 Analyzing data from a contemporary cohort enabled us to characterize the current, stage-specific natural history of NEC, including novel insights into suspected NEC. Future studies could leverage this cohort to characterize how specific patient characteristics, care processes, or biomarkers may influence or predict disease outcomes.

KEY POINTS

· The incidence of NEC has reached a stable baseline in recent years.. · Risk factors for NEC vary in a stage-specific manner.. · The stage-specific onset and progression of NEC differ by gestational age and birth weight..

Safety and Effectiveness of Probiotics in Preterm Infants with Necrotizing Enterocolitis

Although necrotizing enterocolitis is a leading cause of morbidity and mortality among preterm infants, its underlying pathophysiology is not fully understood. Gut dysbiosis, an imbalance between commensal and pathogenic microbes, in the preterm infant is likely a major contributor to the development of necrotizing enterocolitis. In this review, we will discuss the increasing use of probiotics in the NICU, an intervention aimed to mitigate alterations in the gut microbiome. We will review the existing evidence regarding the safety and effectiveness of probiotics, and their potential to reduce rates of necrotizing enterocolitis in preterm infants.

Safety and Effectiveness of Probiotics in Preterm Infants with Necrotizing Enterocolitis

Although necrotizing enterocolitis is a leading cause of morbidity and mortality among preterm infants, its underlying pathophysiology is not fully understood. Gut dysbiosis, an imbalance between commensal and pathogenic microbes, in the preterm infant is likely a major contributor to the development of necrotizing enterocolitis. In this review, we will discuss the increasing use of probiotics in the NICU, an intervention aimed to mitigate alterations in the gut microbiome. We will review the existing evidence regarding the safety and effectiveness of probiotics, and their potential to reduce rates of necrotizing enterocolitis in preterm infants.

Prevalence and risk factors associated with the need for surgical intervention due to necrotizing enterocolitis in very low birth weight infants

INTRODUCTION

Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies affecting very low birth weight (VLBW) infants with an incidence of 6-15 %. Early recognition is crucial. Mortality is high and variable (30-50 %). Those requiring surgical intervention have a higher mortality rate than those who receive medical treatment.

OBJECTIVES

1) To assess the prevalence of surgical NEC and associated risk factors 2) To compare outcomes based on the type of treatment required 3) To estimate the mortality associated with NEC and surgical NEC.

METHODS

A multicentre retrospective cohort study was designed (level II), including VLBW infants born between 2011 and 2020 in Centers of the Neocosur Network. A multivariate logistic regression analysis was performed to evaluate risk factors associated with the need for surgery.

RESULTS

NEC was diagnosed in 1679 (10.4 %) of 16,131 births in this period. The prevalence of surgery was 25 % (95 % CI 23-27 %). In multivariable analysis, variables associated with an increased risk of surgery requirement were birth weight <750 g (aOR 1.73-95%CI 1.2-2.5) and receiving antenatal antibiotics (aOR 1.54-95%CI 1.09-2.74). Those requiring surgery had significantly higher morbidity and mortality than the ones receiving medical treatment.

CONCLUSION

In VLBW infants with NEC, lower birth weight and antenatal antibiotics administration were independently associated with the need for surgical intervention.

Abdominal Wall Movements Predict Intra-Abdominal Pressure Changes in Rats: A Novel Non-Invasive Intra-Abdominal Pressure Detection Method

(1) Background: As increases in intra-abdominal pressure (IAP) result in irreversible tissue damage, monitoring IAP in critically ill patients using the common urinary bladder catheter method is essential. However, this method can result in complications and is not suitable for very low birth weight neonates. The aim of this study was to establish a non-invasive and accurate method to detect IAP changes using an animal model. (2) Methods: IAP changes via intra-abdominal air application (up to 20 mmHg) were measured in 19 Wistar rats via an intra-abdominally placed intracranial pressure probe. Concurrently, abdominal surface tension was measured using a Graseby capsule (GC). (3) Results: A high correlation between abdominal wall distension and IAP (r = 0.9264, CI 0.9249-0.9279) was found for all subjects. (4) Conclusions: IAP changes in rats can be detected non-invasively using a GC. However, further studies are necessary to assess whether IAP changes can be measured using a GC in the neonatal population.

Laparotomy versus Peritoneal Drainage as Primary Treatment for Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation in Preterm Neonates: A Systematic Review and Meta-Analysis

AIM

to systematically review and meta-analyze the impact on morbidity and mortality of peritoneal drainage (PD) compared to laparotomy (LAP) in preterm neonates with surgical NEC (sNEC) or spontaneous intestinal perforation (SIP).

METHODS

Medical databases were searched until June 2022 for studies comparing PD and LAP as primary surgical treatment of preterm neonates with sNEC or SIP. The primary outcome was survival during hospitalization; predefined secondary outcomes included need for parenteral nutrition at 90 days, time to reach full enteral feeds, need for subsequent laparotomy, duration of hospitalization and complications.

RESULTS

Three RCTs (N = 493) and 49 observational studies (N = 19,447) were included. No differences were found in the primary outcome for RCTs, but pooled observational data showed that, compared to LAP, infants with sNEC/SIP who underwent PD had lower survival [48 studies; N = 19,416; RR 0.85; 95% CI 0.79-0.90; GRADE: low]. Observational studies also showed that the subgroup of infants with sNEC had increased survival in the LAP group (30 studies; N = 9370; RR = 0.82; 95% CI 0.72-0.91; GRADE: low).

CONCLUSIONS

Compared to LAP, PD as primary surgical treatment for sNEC or SIP has similar survival rates when analyzing data from RCTs. PD was associated with lower survival rates in observational studies.

The impact of maternal stress on the development of necrotizing enterocolitis: A comprehensive review

Necrotizing Enterocolitis (NEC) is a devastating intestinal inflammatory disease with significant morbidity and mortality. Numerous predictors have been implicated in the development of NEC, with a relatively less emphasis on maternal factors. Pregnancy drives women into a new stage of life that increases their susceptibility to biological and psychological stress. Additionally, maternal stress during pregnancy has been linked to various complications that can negatively impact both the mother and the developing fetus. These detrimental effects are facilitated by various systemic modifications. Similarly, there is evidence from animal studies that suggest a relationship between maternal stress and the occurrence of NEC due to the alterations observed in neonates. In this review, we will (1) discuss the physiological and psychological burden of maternal stress and how it can be linked to NEC, (2) summarize various predictors and risk factors of NEC, and (3) discuss the most widely utilized animal models for assessing the effects of prenatal stress on offspring.

Mixed Feedings and Necrotizing Enterocolitis: The Proportion of Human Milk Matters

Objectives: Impact of the proportion of human milk (HM) in mixed feeding on necrotizing enterocolitis (NEC) remains unknown. This study explores the influence of different proportions of HM on the risk of NEC. Materials and Methods: A retrospective cohort study was performed in infants with very low birth weight (VLBW). A spline smoothing curve was used to evaluate the dose-dependent association between HM and the risk of NEC. Univariate and multivariate analyses were performed to detect the association between the proportion of HM and NEC. Results: Twenty-four infants developed NEC, with 4 (1.9%) in the high HM group, 18 (28.1%) in the low HM group, and 2 (8.0%) in the exclusive formula group (p < 0.001). After adjusting for the relevant confounders, low HM (proportion of HM ≤54%) (OR 33.526, 95% confidential interval [CI] 7.183-156.475, p < 0.001) and exclusive formula feeding (OR 8.493, 95% CI 1.107-65.187, p = 0.040) significantly increased the incidence of NEC, compared with the high HM feeding (proportion of HM >54%). Similarly, low HM was independently associated with an increased risk of feeding intolerance compared with high HM feeding (OR 4.383, 95% CI 2.243-8.564, p < 0.001). Conclusion: A low ratio of HM (≤54%) significantly increased the risk of intestinal complications in VLBW infants. Mixed feeding should relate to the proportion of HM in premature infants.

Sepsis and Mortality Prediction in Very Low Birth Weight Infants: Analysis of HeRO and nSOFA

OBJECTIVE

Scores to predict sepsis or define sepsis severity could improve care for very low birth weight (VLBW) infants. The heart rate characteristics (HRC) index (HeRO score) was developed as an early warning system for late-onset sepsis (LOS), and also rises before necrotizing enterocolitis (NEC). The neonatal sequential organ failure assessment (nSOFA) was developed to predict sepsis-associated mortality using respiratory, hemodynamic, and hematologic data. The aim of this study was to analyze the HRC index and nSOFA near blood cultures in VLBW infants relative to diagnosis and sepsis-associated mortality.

STUDY DESIGN

Retrospective, single-center study of VLBW infants from 2011 to 2019. We analyzed HRC index and nSOFA around blood cultures diagnosed as LOS/NEC. In a subgroup of the cohort, we analyzed HRC and nSOFA near the first sepsis-like illness (SLI) or sepsis ruled-out (SRO) compared with LOS/NEC. We compared scores by diagnosis and mortality during treatment.

RESULTS

We analyzed 179 LOS/NEC, 93 SLI, and 96 SRO blood culture events. In LOS/NEC, the HRC index increased before the blood culture, while nSOFA increased at the time of culture. Both scores were higher in nonsurvivors compared with survivors and in LOS/NEC compared with SRO. The nSOFA 12 hours after the time of blood culture predicted mortality during treatment better than any other time point analyzed (area under the curve 0.91).

CONCLUSION

The HRC index provides earlier warning of imminent sepsis, whereas nSOFA after blood culture provides better prediction of mortality.

KEY POINTS

· The HRC index and nSOFA provide complementary information on sepsis risk and sepsis-related mortality risk.. · This study adds to existing literature evaluating these risk scores independently by analyzing them together and in cases of not only proven but also suspected infections.. · The impact of combining risk models could be improved outcomes for premature infants..

Standardizing Feeding Strategies in Moderately Preterm Infants

Objective

To evaluate the impact of a standardized feeding protocol and donor breast milk (DBM) provision on clinical outcomes in moderate preterm infants (MPT, 29-33 6/7 weeks gestational age).

Study Design

A protocol for MPT infants born > 1500 g was implemented clinically to standardize feeding advancements at 30 mL/kg/day. Infants < 33 weeks received DBM. We retrospectively identified 131 and 144 infants born before and after implementation. Clinical data including central venous line (CVL) placement, feeding tolerance, growth, and provision of maternal breast milk (MBM) were collected.

Result

Number of CVLs, days to full enteral volume (FEV), and MBM provision was unchanged. There was a narrower range of days to FEV post-implementation. Growth metrics were similar between eras.

Conclusion

Implementation of a feeding protocol for MPT infants is associated with more consistent time to FEV With monitoring and appropriate fortification, DBM use in this population is not associated with worse growth outcomes.

Abdominal Surgical Emergencies in Neonates

Abdominal surgical emergencies are relatively common in neonates. Some of them are related to congenital diseases such as intestinal atresia and intestinal malrotation, whereas some are entirely postnatal conditions such as necrotizing enterocolitis and gastric perforation. While there is a wide range of clinical severity for these conditions, outcomes are most favorable with prompt identification and expeditious treatment. In this review, we describe the most common neonatal abdominal surgical emergencies, highlight the signs that can help with early detection, and explain the approach to diagnosis and management.

Implications of racial/ethnic perinatal health inequities on long-term neurodevelopmental outcomes and health services utilization

Infants born preterm and with low birth weight have increased risk for neurodevelopmental challenges later in life compared to term-born peers. These include functional motor impairment, cognitive and speech delays, neurobehavioral disorders, and atypical social development. There are well-documented inequities in the population distributions of preterm birth and associated short-term morbidities by race, ethnicity, language, and nativity. Far less is known about how these inequities affect long-term outcomes, though the impact of unequal access to post-discharge support services for preterm infants raises concerns about widening gaps in health, development, and functioning. In this review, we describe what is currently known about the impact of race, ethnicity, nativity, and language on long-term outcomes. We provide a framework for understanding inequities in social, political, and historical context. And we offer guidance for next steps to delineate mechanistic pathways and to identify interventions to eliminate inequities in long-term neurodevelopmental outcomes through research, intervention, and advocacy.

Feeding in Preterm Neonates With Antenatal Doppler Abnormalities: A Systematic Review and Meta-Analysis

OBJECTIVES

In this systematic review and meta-analysis, we attempted to determine the most appropriate feed initiation and advancement practices in preterm neonates with antenatal Doppler abnormalities.

METHODS

We included randomized controlled trials comparing different feed initiation and advancement practices in neonates with antenatal Doppler abnormalities. The databases of PubMed, Embase, Cochrane, CINAHL, Scopus, and Google Scholar were searched on February 25, 2022. The risk of bias was assessed using the Risk of Bias tool, version 2. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RevMan 5.4 was used for data analysis.

RESULTS

Of the 1499 unique records identified, 7 studies were eligible for inclusion (6 on feed initiation, 1 on feed advancement). Early enteral feeding did not increase NEC stage 2 or more [risk ratio (RR) 1.12, 95% confidence interval (CI) 0.71-1.78; 6 studies, 775 participants] and mortality (RR 0.83, 95% CI 0.47-1.48; 5 studies, 642 participants). A trend was noted towards an increase in feeding intolerance (RR 1.23, 95% CI 0.98-1.56; 5 studies, 715 participants). There was a significant reduction in age at full enteral feeds, duration of total parental nutrition, and rates of hospital-acquired infections. Rapid feed advancement decreased the age at full enteral feeds without affecting other outcomes. The overall certainty of the evidence was rated low. Heterogeneity was not significant.

CONCLUSION

There is low-certainty evidence that early feed initiation in preterm neonates with antenatal Doppler abnormalities does not increase rates of NEC and mortality. There is insufficient data on the speed of feed advancement.

Macrophage-derived IGF-1 protects the neonatal intestine against necrotizing enterocolitis by promoting microvascular development

Necrotizing enterocolitis (NEC) is a deadly bowel necrotic disease of premature infants. Low levels of plasma IGF-1 predispose premature infants to NEC. While increasing evidence suggests that defective perinatal intestinal microvascular development plays a role in NEC, the involved mechanism remains incompletely understood. We report here that serum and intestinal IGF-1 are developmentally regulated during the perinatal period in mice and decrease during experimental NEC. Neonatal intestinal macrophages produce IGF-1 and promote endothelial cell sprouting in vitro via IGF-1 signaling. In vivo, in the neonatal intestine, macrophage-derived IGF-1 promotes VEGF expression and endothelial cell proliferation and protects against experimental NEC. Exogenous IGF-1 preserves intestinal microvascular density and protects against experimental NEC. In human NEC tissues, villous endothelial cell proliferation and IGF-1- producing macrophages are decreased compared to controls. Together, our results suggest that defective IGF-1-production by neonatal macrophages impairs neonatal intestinal microvascular development and predisposes the intestine to necrotizing enterocolitis.

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of necrotizing enterocolitis: A prospective study

BACKGROUND AND PURPOSE

Necrotizing enterocolitis (NEC) is a critical gastrointestinal disease. We aim to explore the value of fecal human β-defensin 2 (HBD-2), Claudin-3, high-mobility group box-1 protein (HMGB-1), and resistin-like molecule β (Relmβ) as well as some laboratory metrics to predict the deterioration of NEC.

METHODS

Infants diagnosed with NEC at Stage II were enrolled in our study. Those who progressed to Stage III were included in the Stage III group and the rest were included in the Stage II group. Clinical data and laboratory metrics of the infants were collected. Fecal samples of HBD2, HMGB-1, Claudin-3, and Relmβ collected during their enrollment were determined by using enzyme-linked immunosorbent assay (ELISA) kits. Student's t-test, the Mann-Whitney U test, the chi-square test, receiver operating characteristic (ROC), and logistic regression analysis were performed.

RESULTS

Sixty infants diagnosed with NEC at Stage II were enrolled in our study, with 27 in the Stage III group (n = 27) and 33 in the Stage II group (n = 33). Although many of these NEC cases were late preterm and term infants, the infants in the Stage III group had a lower gestational age (P < 0.05). The incidence of gestational diabetes mellitus, peritonitis, intestinal adhesion, and sepsis was higher and more infants in the Stage III group underwent surgeries (P < 0.05). The levels of HBD-2 and Claudin-3 were higher and neutrophil count was lower in the Stage III group than in the Stage II Group, and the area under the curve (AUC) was 0.754, 0,755, and 0.666, respectively (P < 0.05). HBD-2 ≥ 1649.02 ng/g and Claudin-3 ≥ 2488.71 pg/g were included in the multivariate stepwise logistic regression analysis (P < 0.05), and the AUC of the model was 0.805 (95% CI: 0.688-0.922).

CONCLUSION

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of NEC from Stage II to Stage III.

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths

OBJECTIVE

The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants.

STUDY DESIGN

A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality.

RESULTS

Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change.

CONCLUSION

A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC.

KEY POINTS

· QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Clinical Presentation and Multifactorial Pathogenesis of Necrotizing Enterocolitis in the Preterm Infant

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious infection of the bowel wall induced by multiple pathological factors, which include inflammation and tissue invasion with bacteria known to cause severe infections. NEC is now understood to be several disease processes under one umbrella. The most common form occurs in premature infants and can exert significant impacts to preterm morbidity and mortality.

PURPOSE

This narrative review describes current knowledge of the clinical presentation and pathophysiology of NEC in premature infants.

METHODS/SEARCH STRATEGY

A review of literature was conducted using key words in PubMed and CINAHL with preference for years 2015 to 2020.

FINDINGS/RESULTS

Several converging and interrelated factors including characteristics of the premature intestinal mucosa, gut ischemia, dysregulation of the microbiome, enteral feeding, and genetics create an environment where NEC is more likely to occur.

IMPLICATIONS FOR PRACTICE

To recognize and diagnose NEC in preterm infants, an understanding of underlying factors that create an optimal environment for disease acquisition in premature infants is essential.

IMPLICATIONS FOR RESEARCH

Prevention of NEC remains the most important strategy for decreasing morbidity and mortality. Multiple areas of potential study exist for NEC pathophysiology including those that consider how the factors discussed in this review are interrelated and how each particular pathway can be optimized to prevent the onset of NEC.

Probiotics, Prebiotics, and Synbiotics for the Prevention of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a major cause of morbidity and mortality in preterm infants. The exact mechanism by which NEC develops is poorly understood however there is growing evidence to suggest that perturbations in the early-life gut microbiota composition increase the risk for NEC. Modulation of the gut microbiota with probiotics, prebiotics, or in combination (synbiotics) is an area which has attracted intense interest in recent years. In this narrative review, we present an overview of the role of the gut microbiota in the pathogenesis of NEC. We also examine the evidence currently available from randomized controlled trials, observational studies, systematic reviews, and meta-analysis examining the role of probiotics, prebiotics, and synbiotics in reducing the risk of or preventing NEC. Current clinical practice guidelines with recommendations on the routine administration of probiotics to preterm infants for NEC are also explored.

Feeding Twins with Human Milk and Factors Associated with Its Duration: A Qualitative and Quantitative Study in Southern Italy

BACKGROUND

Over the past year, there has been a rise in twin births. The current scientific consensus recommended breast-feed milk for all newborns for at least 6 months. They stated that it is possible to meet the nutritional needs of two or more newborns with only one mother's milk. More information would be desirable about the factors that influence or lead to the initiation and interruption of breastfeeding. The quality of the evidence available from multiple studies has been inconclusive and therefore led to controversial interpretations and practices.

AIMS

The first aim of this study was to analyze the extent of the feeding of multiples with breast milk in the experience of our clinical unit in terms of incidence and duration. The second objective was to evaluate the correlation between maternal, perinatal and neonatal variables with breast milk feeding rates and duration.

METHODS

The study was conducted between 2015 and 2020, in a NICU in Southern Italy (San Giovanni Rotondo, Foggia). Sixty-one women who have given birth to multiples were enrolled into the study. Newborn data were retrospectively collected by informatic database and breastfeeding information were collected by a questionnaire.

RESULTS

In our centre, the percentage of twins out of the total number of births over the years has almost doubled from 1.28% in 2015 to 2.48% in 2020 and the 88% of twins are premature. 18.1% received breast milk for more than 6 months and 6.3% received it for more than 12 months. Infants of lower gestational age and weight, born to multiparous, more mature and medium-high schooling mothers received breast milk for a longer period. 35% of women explained that the interruption of breastfeeding was due to the insufficient milk production and 41% to the stress and difficulties in managing the twins. Qualitative analysis of maternal narrative revealed, for many of them, the awareness of the importance of breastfeeding and the efforts made to try to give breast milk, but also fears about the quantity of milk and satiety of their children.

CONCLUSIONS

It is important to identify the factors both favoring and obstructing maternal milk feeding of multiples and it would be desirable the activation of a network of training and support for mothers after discharge, with particular regard to the categories found to be less inclined.

Necrotizing Enterocolitis in Children with Congenital Heart Disease: A Literature Review

Infants with congenital heart disease (CHD) are at an increased risk of developing necrotising enterocolitis (NEC), a serious inflammatory intestinal condition classically associated with prematurity. CHD not only increases the risk of NEC in preterm infants but is one of the most commonly implicated risk factors in term infants. Existing knowledge on the topic is limited largely to retrospective studies. This review acts to consolidate existing knowledge on the topic in terms of disease incidence, pathophysiology, risk factors, outcomes and the complex relationship between NEC and enteral feeds. Potential preventative strategies, novel biomarkers for NEC in this population, and the role of the intestinal microbiome are all explored. Numerous challenges exist in the study of this complex multifactorial disease which arise from the heterogeneity of the affected population and its relative scarcity. Nevertheless, its high related morbidity and mortality warrant renewed interest in identifying those infants most at risk and implementing strategies to reduce the incidence of NEC in infants with CHD.

Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants

OBJECTIVE

To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants.

METHODS

This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation.

RESULTS

Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047).

CONCLUSION

Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.

Precision-based modeling approaches for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in premature infants and remains stubbornly difficult to treat in many cases. Much of our understanding of NEC pathogenesis has been gained through the study of highly translational animal models. However, most models of NEC are limited by their overall complexity and by the fact that they do not incorporate human tissue. To address these limitations, investigators have recently developed precision-based ex vivo models of NEC, also termed ‘NEC-in-a-dish’ models, which provide the opportunity to increase our understanding of this disease and for drug discovery. These approaches involve exposing intestinal cells from either humans or animals with or without NEC to a combination of environmental and microbial factors associated with NEC pathogenesis. This Review highlights the current progress in the field of NEC model development, introduces NEC-in-a-dish models as a means to understand NEC pathogenesis and examines the fundamental questions that remain unanswered in NEC research. By answering these questions, and through a renewed focus on precision model development, the research community may finally achieve enduring success in improving the outcome of patients with this devastating disease.

Summary: Much of our understanding of necrotizing enterocolitis (NEC) pathogenesis has been achieved through animal models. Here, we discuss the development of advanced precision-based models to improve outcomes for patients with NEC.

Developmental 2,3,7,8-tetrachlorodibenzo-p-dioxin exposure of either parent enhances the risk of necrotizing enterocolitis in neonatal mice

BACKGROUND

Necrotizing enterocolitis (NEC) is a rare, but potentially fatal intestinal inflammatory condition most often arising in premature infants. Infants provided formula are also at greater risk of developing this disease. Although the majority of formula-fed, preterm infants do not develop NEC, up to 30% of infants with the disease do not survive. Thus, identifying additional, currently unrecognized factors, which may predispose a specific infant to NEC development would be a significant clinical advancement. In this regard, we have previously reported that offspring of female or male mice with a history of developmental exposure to the environmental toxicant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exhibit altered sensitivity to inflammatory challenges and are frequently born premature. Herein, we examined the possibility that, compared to unexposed mice (F1_NONE ), developmental TCDD exposure of either parent (maternal, F1M_TCDD , or paternal, F1P_TCDD ) would enhance the risk of NEC in offspring (F2_TCDD mice) in association with supplemental formula feeding.

METHODS

Beginning on postnatal day 7, all neonates were randomized to maternal milk only or maternal milk with up to 20 supplemental formula feedings. All pups remained with the Dams and were additionally allowed to nurse ad libitum.

RESULTS

Formula-fed F2_NONE pups rarely developed NEC while this disease was common in formula-fed F2M_TCDD and F2P_TCDD mice. Unexpectedly, 50% of F2M_TCDD pups that were not provided supplemental formula also developed NEC.

CONCLUSIONS

Our studies provide evidence that a history of parental TCDD exposure enhances the risk of NEC in offspring and suggest exposure to environmental immunotoxicants such as TCDD may also contribute to this inflammatory disease in humans.

Determinants of preterm infants’ deaths at the Neonatal Intensive Care Units in the Northeast Countryside in Brazil

Abstract Objectives: to assess preterm infants’ characteristics, health conditions and neonatal care effect on their death at the neonatal ICU. Methods: this was a non-concurrent cohort study, including preterm infants from three neonatal ICUs from January 1st to December 31st, 2016, followed during the neonatal period and deaths registered during the entire hospitalization. Multivariate analysis was performed using Poisson regression. Results: of the 181 preterm infants, 18.8% died during hospitalization. Associated with the outcome: a gestational age between 28 and 32 weeks (RR= 5.66; CI95%= 2.08-15.40), and less than 28 weeks (RR=9.24; CI95%=3.27-26.12), Apgar score of 5th minutes less than 7 (RR: 1.82; CI95%=1.08-3.08), use of invasive mechanical ventilation up to 3 days (RR= 4.44; CI95%= 1.66-11.87) and 4 days and more (RR=6.87; CI95%=2.58-18.27). Besides the late sepsis (RR: 3.72, CI95%=1.77-7.83), acute respiratory distress syndrome (RR=2.86, CI95%=1.49-5.46), pulmonary hemorrhage (RR=1.97; CI95%=1.40-2.77), and necrotizing enterocolitis (RR= 3.41; CI95%=1.70-6.83). Conclusions: the results suggest the importance of using strategies to improve care during childbirth, conditions for extremely premature infants, early weaning from a mechanical ventilation and prevention on nosocomial infection.

Does the contribution of human milk oligosaccharides to the beneficial effects of breast milk allow us to hope for an improvement in infant formulas?

Human milk is a source of nutrients and contains many distinct bioactive components. Among these, human milk oligosaccharides (HMOs) have attracted considerable attention and are being investigated as a "novel foods". Human milk is unique in its oligosaccharide composition. Recent research has focused on the complexity of HMOs by highlighting their diversity, structural variability, concentration variance, and structure-function relationships. In vitro and in vivo studies have demonstrated that HMOs drive infant gut microbiota, improve intestinal barrier functions, and modulate cell receptor signaling, thereby contributing to the development of infant immunity. These studies, combined with epidemiological data, indicate that some HMO may confer health benefits by preventing infections and diseases such as necrotizing enterocolitis and allergies. However, randomized controlled trials are restricted to structurally simple compounds such as 2' fucosyllactose and lacto-N-neotetraose. More controlled clinical trials are needed to justify routine supplementation of formula. It is felt that a better understanding of the role of HMOs leading to the development of inexpensive methods for large-scale HMO production is needed.

A randomized controlled trial protocol comparing the feeds of fresh versus frozen mother's own milk for preterm infants in the NICU

Background

Necrotizing enterocolitis (NEC) is the leading cause of death among preterm infants born at < 30 weeks’ gestation. The incidence of NEC is reduced when infants are fed human milk. However, in many neonatal intensive care units (NICUs), it is standard practice to freeze and/or pasteurize human milk, which deactivates bioactive components that may offer additional protective benefits. Indeed, our pilot study showed that one feed of fresh mother’s own milk per day was safe, feasible, and can reduce morbidity in preterm infants. To further evaluate the benefits of fresh human milk in the NICU, a randomized controlled trial is needed.

Methods

Our prospective multicenter, double-blinded, randomized, controlled trial will include infants born at < 30 weeks’ gestation and admitted to one of 29 tertiary NICUs in China. Infants in the intervention (fresh human milk) group (n = 1549) will receive at least two feeds of fresh human milk (i.e., within 4 h of expression) per day from the time of enrollment until 32 weeks’ corrected age or discharge to home. Infants in the control group (n = 1549) will receive previously frozen human milk following the current standard protocols. Following informed consent, enrolled infants will be randomly allocated to the control or fresh human milk groups. The primary outcome is the composite outcome mortality or NEC ≥ stage 2 at 32 weeks’ corrected age, and the secondary outcomes are mortality, NEC ≥ stage 2, NEC needing surgery, late-onset sepsis, retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), weight gain, change in weight, increase in length, increase in head circumference, time to full enteral feeds, and finally, the number and type of critical incident reports, including feeding errors.

Discussion

Our double-blinded, randomized, controlled trial aims to examine whether fresh human milk can improve infant outcomes. The results of this study will impact both Chinese and international medical practice and feeding policy for preterm infants. In addition, data from our study will inform changes in health policy in NICUs across China, such that mothers are encouraged to enter the NICU and express fresh milk for their infants.

Trial registration

Chinese Clinical Trial Registry; #ChiCTR1900020577; registered January 1, 2019; http://www.chictr.org.cn/showprojen.aspx?proj=34276

Preventive strategies and factors associated with surgically treated necrotising enterocolitis in extremely preterm infants: an international unit survey linked with retrospective cohort data analysis

OBJECTIVES

To compare necrotising enterocolitis (NEC) prevention practices and NEC associated factors between units from eight countries of the International Network for Evaluation of Outcomes of Neonates, and to assess their association with surgical NEC rates.

DESIGN

Prospective unit-level survey combined with retrospective cohort study.

SETTING

Neonatal intensive care units in Australia/New Zealand, Canada, Finland, Israel, Spain, Sweden, Switzerland and Tuscany (Italy).

PATIENTS

Extremely preterm infants born between 24⁰ to 28⁶ weeks' gestation, with birth weights<1500 g, and admitted between 2014-2015.

EXPOSURES

NEC prevention practices (probiotics, feeding, donor milk) using responses of an on-line pre-piloted questionnaire containing 10 questions and factors associated with NEC in literature (antenatal steroids, c-section, indomethacin treated patent ductus arteriosus and sepsis) using cohort data.

OUTCOME MEASURES

Surgical NEC rates and death following NEC using cohort data.

RESULTS

The survey response rate was 91% (153 units). Both probiotic provision and donor milk availability varied between 0%-100% among networks whereas feeding initiation and advancement rates were similar in most networks. The 9792 infants included in the cohort study to link survey results and cohort outcomes, revealed similar baseline characteristics but considerable differences in factors associated with NEC between networks. 397 (4.1%) neonates underwent NEC surgery, ranging from 2.4%-8.4% between networks. Standardised ratios for surgical NEC were lower for Australia/New Zealand, higher for Spain, and comparable for the remaining six networks.

CONCLUSIONS

The variation in implementation of NEC prevention practices and in factors associated with NEC in literature could not be associated with the variation in surgical NEC incidence. This corroborates the current lack of consensus surrounding the use of preventive strategies for NEC and emphasises the need for research.

Necrotizing Enterocolitis: Enhancing Awareness for the General Practitioner

Necrotizing enterocolitis (NEC) has been recognized for well over 5 decades yet remains the most common life-threatening surgical emergency in the newborn. The incidence of NEC has decreased steadily in preterm and very-low-birthweight infants over several decades and is typically uncommon in term newborns and infants with a birthweight greater than 2,500 g. Evidence accumulating during the past decade, however, suggests that practitioners should consider NEC in this broader subset of term infants with chromosomal and congenital anomalies complicated by heart or gastrointestinal defects when signs and symptoms of feeding intolerance, abdominal illness, or sepsis are present. The short- and long-term consequences of NEC are devastating in all infants, and although early disease recognition and treatment are essential, promoting human milk feeding as a primary modality in prevention is critical. This article highlights our current understanding of the pathophysiology, the clinical presentation, the risk factors for NEC in term infants compared with premature infants, and the treatment of NEC and discusses strategies in the prevention of NEC. Finally, we review the long-term consequences of NEC and the importance of primary care practitioners in the long-term care of infants after hospitalization for NEC.

Necrotizing Enterocolitis Reduction Using an Exclusive Human-Milk Diet and Probiotic Supplementation in Infants With 1000-1499 Gram Birth Weight

BACKGROUND

Necrotizing enterocolitis (NEC) is a major complication confronting clinicians caring for premature infants. This investigation compares clinical outcomes before and after quality improvement-program interventions in a population of premature infants at intermediate risk for NEC.

METHODS

This study is a retrospective single-center chart review of infants admitted with a birth weight of 1000-1499 g, excluding major congenital anomalies, over a 6-year period, beginning with implementation of a donor breast-milk program when mother's own milk was not available. Infants were separated into 2 epochs, before (July 2012-December 2013) and after (April 2014-June 2018) introduction of human milk-derived fortifier (Prolacta) and a daily probiotic (FloraBABY) supplement.

RESULTS

Comparing 140 preintervention infants with 265 postintervention infants, NEC was significantly lower in the postintervention group: 5.2% vs 1.1% (P = 0.046). Somatic growth was similar in both epochs.

CONCLUSIONS

Quality-improvement initiatives utilizing an exclusive human-milk diet and daily probiotic supplementation were associated with a decreased incidence of NEC in infants with a birth weight of 1000-1499 g. Implementation of the NEC reduction bundle did not affect infant growth.

To start or not: Factors to consider when implementing routine probiotic use in the NICU

Supplementation of probiotics to very low birth weight (VLBW) infants has been extensively studied, with multiple meta-analyses reporting probiotics decrease the risk of necrotizing enterocolitis (NEC) and death. Despite availability of this evidence, the decision to initiate routine probiotic supplementation to preterm infants continues to be a complex one. There are uncertainties regarding the use of probiotics, including selecting the appropriate product, dose and target population. Additionally, availability of specific probiotic products and regulatory oversight varies by country, raising concerns regarding the safety and efficacy of specific probiotic products. In this review, we summarize the latest evidence on probiotic use in preterm infants and discuss considerations that may help guide clinicians who are considering routine probiotic supplementation.

Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review

The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.

Nutritional Support of Very Low Birth Weight Infants in a Tertiary Center in a Developing Country

BACKGROUND

Very low birth weight infants (VLBWIs) are at high risk for nutritional deficiency. Enteral feeding is usually challenged by increased risk of necrotizing enterocolitis (NEC). The nutritional needs of VLBWIs are usually dependent on parenteral nutrition during early postnatal life. This study aimed to evaluate the nutritional service of VLBWIs at Jordan University Hospital.

METHODS

This was a prospective follow-up study of VLBWIs with birth weight ≤ 1,500 g. Data were extracted from medical charts and laboratory database.

RESULTS

In total, 43 VLBWIs met our inclusion criteria; of them, 21% were extremely low birth weight infants (ELBWIs). The mean gestational age was 29 weeks, and the mean birth weight was 1,218 g. The mean age of starting feeds was 3 days. Mean full feed age is 2 weeks. The most common side effect of total parenteral nutrition (TPN) was hypertriglyceridemia (35%).

CONCLUSIONS

Nutritional care of VLBWIs is well established in our center. Initiating fortification earlier and working to increase mother's own breast milk supply is vital to improve growth in low resource setting.

Closing the Gap Between Recommended and Actual Human Milk Use for Fragile Infants: What Will It Take to Overcome Disparities?

This article describes the components of human milk and their value to reduce risk for necrotizing enterocolitis, disparities in access to human milk, potential relationships to care practices within the neonatal intensive care unit, and ways to overcome the disparity.

Toll-Like Receptor-Mediated Intestinal Inflammatory Imbalance in the Pathogenesis of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) remains the leading cause of death from gastrointestinal disease in premature infants and attacks the most fragile patients at a time when they appear to be the most stable. Despite significant advances in our overall care of the premature infant, NEC mortality remains stubbornly high. There is no specific treatment for NEC beyond broad-spectrum antibiotics and intestinal resection, and current efforts have focused on preventive strategies. Over the past decade, we have proposed a unifying hypothesis to explain the pathogenesis of NEC in premature infants that suggests that NEC develops in response to an imbalance between exaggerated proinflammatory signaling in the mucosa of the premature gut leading to mucosal injury, which is not countered effectively by endogenous repair processes, and in the setting of impaired mesenteric perfusion leads to intestinal ischemia and disease development. One of the most important pathways that mediates the balance between injury and repair in the premature intestine, and that plays a key role in NEC pathogenesis, is Toll-like receptor 4 (TLR4), which recognizes lipopolysaccharide on gram-negative bacteria. This review focuses on the role that the TLR4-mediated imbalance between proinflammatory and anti-inflammatory signaling in the premature intestinal epithelium leads to the development of NEC, and will explore how an understanding of the role of TLR4 in NEC pathogenesis has led to the identification of novel preventive or treatment approaches for this devastating disease.

Neonatal intestinal dysbiosis in necrotizing enterocolitis

Necrotizing Enterocolitis (NEC) is one of the most devastating gastrointestinal diseases in neonates, particularly among preterm infants in whom surgical NEC is the leading cause of morbidity. NEC pathophysiology occurs in the hyper-reactive milieu of the premature gut after bacterial colonization. The resultant activation of the TLR4 pathway appears to be a strongly contributing factor. Advancements in metagenomics may yield new clarity to the relationship between the neonatal intestinal microbiome and the development of NEC. After a century without effective directed treatments, microbiome manipulation offers a promising therapeutic target for the prevention and treatment of this devastating disease.

Neonatal Bowel Disorders: Practical Imaging Algorithm for Trainees and General Radiologists

OBJECTIVE

Neonatal bowel disorders require prompt and accurate diagnosis to avoid potential morbidity and mortality. Symptoms such as feeding intolerance, emesis, or failure to pass meconium may prompt a radiologic evaluation.

CONCLUSION

We discuss the most common neonatal bowel disorders and present a practical imaging algorithm for trainees and general radiologists.

Human milk and necrotizing enterocolitis

NEC is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Human milk feedings, both from the infant's mother and donor human milk, have been associated with reductions in NEC in preterm infants. This article will review the protective factors in human milk, clinical studies of human milk and NEC, and practices to enhance human milk use in neonatal intensive care units.