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Vievermanns K, Dierikx TH, Oldenburger NJ, Jamaludin FS, Niemarkt HJ, de Meij TGJ. Effect of probiotic supplementation on the gut microbiota in very preterm infants: a systematic review. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326691. [PMID: 38925919 DOI: 10.1136/archdischild-2023-326691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/13/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE There is increasing evidence that probiotic supplementation in very preterm infants decreases the risk of necrotising enterocolitis (NEC), sepsis and mortality. The underlying mechanisms, including effects on the gut microbiota, are largely unknown. We aimed to systematically review the available literature on the effects of probiotic supplementation in very preterm infants on gut microbiota development. DESIGN A systematic review in Medline, Embase, Cochrane Library, CINAHL and Web of Science. SETTING Neonatal intensive care unit. PATIENTS Premature infants. INTERVENTION Probiotic supplementation. MAIN OUTCOME MEASURES Gut microbiota. RESULTS A total of 1046 articles were screened, of which 29 were included. There was a large heterogeneity in study design, dose and type of probiotic strains, timepoints of sample collection and analysing techniques. Bifidobacteria and lactobacilli were the most used probiotic strains. The effects of probiotics on alpha diversity were conflicting; however, beta diversity was significantly different between probiotic-supplemented infants and controls in the vast majority of studies. In most studies, probiotic supplementation led to increased relative abundance of the supplemented strains and decreased abundance of genera such as Clostridium, Streptococcus, Klebsiella and Escherichia. CONCLUSIONS Probiotic supplementation to preterm infants seems to increase the relative abundance of the supplemented strains with a concurrent decrease of potentially pathogenic species. These probiotic-induced microbial alterations may contribute to the decreased risk of health complications such as NEC. Future trials, including omics technologies to analyse both microbiota composition and function linked to health outcomes, are warranted to identify the optimal mixture and dosing of probiotic strains. PROSPERO REGISTRATION NUMBER CRD42023385204.
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Affiliation(s)
- Kayleigh Vievermanns
- Pediatric Gastroenterology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Thomas H Dierikx
- Pediatric Gastroenterology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Microbiology, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Faridi S Jamaludin
- Medical Library AMC, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Hendrik J Niemarkt
- Neonatology, Maxima Medisch Centrum locatie Veldhoven, Veldhoven, The Netherlands
- Electrical Engineering, TU Eindhoven, Eindhoven, The Netherlands
| | - Tim G J de Meij
- Pediatric Gastroenterology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Pediatric Gastroenterology, Emma children's hospital amsterdam, Amsterdam, The Netherlands
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2
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Baucells BJ, Sebastiani G, Herrero-Aizpurua L, Andreu-Fernández V, Navarro-Tapia E, García-Algar O, Figueras-Aloy J. Effectiveness of a probiotic combination on the neurodevelopment of the very premature infant. Sci Rep 2023; 13:10344. [PMID: 37365274 DOI: 10.1038/s41598-023-37393-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023] Open
Abstract
Probiotics have shown a benefit in reducing necrotising enterocolitis in the premature infant, however the study of their effect on premature neonates' neurodevelopment is limited. The aim of our study was to elucidate whether the effect of Bifidobacterium bifidum NCDO 2203 combined with Lactobacillus acidophilus NCDO 1748 could positively impact the neurodevelopment of the preterm neonates. Quasi-experimental comparative study with a combined treatment of probiotics in premature infants < 32 weeks and < 1500 g birth weight, cared for at a level III neonatal unit. The probiotic combination was administered orally to neonates surviving beyond 7 days of life, until 34 weeks postmenstrual age or discharge. Globally, neurodevelopment was evaluated at 24 months corrected age. A total of 233 neonates were recruited, 109 in the probiotic group and 124 in the non-probiotic group. In those neonates receiving probiotics, there was a significant reduction in neurodevelopment impairment at 2 years of age RR 0.30 [0.16-0.58], and a reduction in the degree of impairment (normal-mild vs moderate-severe, RR 0.22 [0.07-0.73]). Additionally, there was a significant reduction in late-onset sepsis (RR 0.45 [0.21-0.99]). The prophylactic use of this probiotic combination contributed to improving neurodevelopmental outcome and reduced sepsis in neonates born at < 32 weeks and < 1500 g.Per style, a structured abstract is not allowed so we have changed the structured abstract to an unstructured abstract. Please check and confirm.Accepted.
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Affiliation(s)
- Benjamin James Baucells
- Neonatology Service Hospital Clínic-Maternitat, ICGON, BCNatal, Carrer Sabino Arana 1, 08028, Barcelona, Spain.
| | - Giorgia Sebastiani
- Neonatology Service Hospital Clínic-Maternitat, ICGON, BCNatal, Carrer Sabino Arana 1, 08028, Barcelona, Spain
- Grup de Recerca Infància i Entorn (GRIE), Institut d'investigacions Biomèdiques August pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Vicente Andreu-Fernández
- Grup de Recerca Infància i Entorn (GRIE), Institut d'investigacions Biomèdiques August pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biosanitary Research Institute, Valencian International University (VIU), Valencia, Spain
| | - Elisabet Navarro-Tapia
- Grup de Recerca Infància i Entorn (GRIE), Institut d'investigacions Biomèdiques August pi i Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Oscar García-Algar
- Neonatology Service Hospital Clínic-Maternitat, ICGON, BCNatal, Carrer Sabino Arana 1, 08028, Barcelona, Spain
| | - Josep Figueras-Aloy
- Neonatology Service Hospital Clínic-Maternitat, ICGON, BCNatal, Carrer Sabino Arana 1, 08028, Barcelona, Spain
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3
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Rao S, Esvaran M, Chen L, Kok C, Keil AD, Gollow I, Simmer K, Wemheuer B, Conway P, Patole S. Probiotic supplementation for neonates with congenital gastrointestinal surgical conditions: guidelines for future research. Pediatr Res 2023; 93:49-55. [PMID: 35505080 PMCID: PMC9876795 DOI: 10.1038/s41390-022-02087-8] [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] [Received: 01/09/2022] [Revised: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 01/29/2023]
Abstract
Our pilot RCT found that probiotic supplementation with the three-strain bifidobacterial product (B. breve M-16V, B. longum subsp. infantis M-63 and B. longum subsp. longum BB536) attenuates gut dysbiosis, increases stool short-chain fatty acid (SCFA) levels and improves the growth of head circumference in neonates with congenital gastrointestinal surgical conditions (CGISC). In this article, we have provided guidelines for designing future multicentre RCTs based on the experience gained from our pilot RCT. The recommendations include advice about sample size, potential confounders, outcomes of interest, probiotic strain selection, storage, dose, duration and microbial quality assurance, collection of stool samples, storage and analysis and reporting. Following these guidelines will increase the validity of future RCTs in this area and hence confidence in their results. IMPACT: Probiotic supplementation attenuates gut dysbiosis, increases stool short-chain fatty acid (SCFA) levels and improves the growth of head circumference in neonates with congenital gastrointestinal surgical conditions. The current review provides evidence-based guidelines to conduct adequately powered RCTs in this field.
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Affiliation(s)
- Shripada Rao
- Neonatal Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia. .,Neonatal Intensive Care Unit, King Edward Memorial Hospital for Women, Perth, WA, Australia. .,School of Medicine, University of Western Australia, Crawley, WA, Australia.
| | - Meera Esvaran
- grid.1005.40000 0004 4902 0432Centre for Marine Science and Innovation at the University of New South Wales (UNSW), Sydney, NSW Australia
| | - Liwei Chen
- grid.59025.3b0000 0001 2224 0361School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore, Singapore
| | - Chooi Kok
- grid.410667.20000 0004 0625 8600Neonatal Intensive Care Unit, Perth Children’s Hospital, Perth, WA Australia ,grid.415259.e0000 0004 0625 8678Neonatal Intensive Care Unit, King Edward Memorial Hospital for Women, Perth, WA Australia
| | - Anthony D. Keil
- grid.2824.c0000 0004 0589 6117Department of Microbiology, PathWest Laboratory Medicine, Perth, WA Australia
| | - Ian Gollow
- grid.410667.20000 0004 0625 8600Department of Paediatric Surgery, Perth Children’s Hospital, Perth, WA Australia
| | - Karen Simmer
- grid.410667.20000 0004 0625 8600Neonatal Intensive Care Unit, Perth Children’s Hospital, Perth, WA Australia ,grid.415259.e0000 0004 0625 8678Neonatal Intensive Care Unit, King Edward Memorial Hospital for Women, Perth, WA Australia ,grid.1012.20000 0004 1936 7910School of Medicine, University of Western Australia, Crawley, WA Australia
| | - Bernd Wemheuer
- grid.1005.40000 0004 4902 0432Centre for Marine Science and Innovation at the University of New South Wales (UNSW), Sydney, NSW Australia ,grid.7450.60000 0001 2364 4210Department of Genomic and Applied Microbiology, University of Göttingen, Göttingen, Germany
| | - Patricia Conway
- grid.1005.40000 0004 4902 0432Centre for Marine Science and Innovation at the University of New South Wales (UNSW), Sydney, NSW Australia ,grid.59025.3b0000 0001 2224 0361School of Chemical and Biomedical Engineering, Nanyang Technological University, Singapore, Singapore
| | - Sanjay Patole
- grid.410667.20000 0004 0625 8600Neonatal Intensive Care Unit, Perth Children’s Hospital, Perth, WA Australia ,grid.415259.e0000 0004 0625 8678Neonatal Intensive Care Unit, King Edward Memorial Hospital for Women, Perth, WA Australia ,grid.1012.20000 0004 1936 7910School of Medicine, University of Western Australia, Crawley, WA Australia
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Beck LC, Masi AC, Young GR, Vatanen T, Lamb CA, Smith R, Coxhead J, Butler A, Marsland BJ, Embleton ND, Berrington JE, Stewart CJ. Strain-specific impacts of probiotics are a significant driver of gut microbiome development in very preterm infants. Nat Microbiol 2022; 7:1525-1535. [PMID: 36163498 PMCID: PMC9519454 DOI: 10.1038/s41564-022-01213-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/25/2022] [Indexed: 12/23/2022]
Abstract
The development of the gut microbiome from birth plays important roles in short- and long-term health, but factors influencing preterm gut microbiome development are poorly understood. In the present study, we use metagenomic sequencing to analyse 1,431 longitudinal stool samples from 123 very preterm infants (<32 weeks' gestation) who did not develop intestinal disease or sepsis over a study period of 10 years. During the study period, one cohort had no probiotic exposure whereas two cohorts were given different probiotic products: Infloran (Bifidobacterium bifidum and Lactobacillus acidophilus) or Labinic (B. bifidum, B. longum subsp. infantis and L. acidophilus). Mothers' own milk, breast milk fortifier, antibiotics and probiotics were significantly associated with the gut microbiome, with probiotics being the most significant factor. Probiotics drove microbiome transition into different preterm gut community types (PGCTs), each enriched in a different Bifidobacterium sp. and significantly associated with increased postnatal age. Functional analyses identified stool metabolites associated with PGCTs and, in preterm-derived organoids, sterile faecal supernatants impacted intestinal, organoid monolayer, gene expression in a PGCT-specific manner. The present study identifies specific influencers of gut microbiome development in very preterm infants, some of which overlap with those impacting term infants. The results highlight the importance of strain-specific differences in probiotic products and their impact on host interactions in the preterm gut.
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Affiliation(s)
- Lauren C Beck
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Andrea C Masi
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Gregory R Young
- Hub for Biotechnology in the Built Environment, Northumbria University, Newcastle, UK
| | - Tommi Vatanen
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Christopher A Lamb
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Rachel Smith
- Bioscience Institute, Newcastle University, Newcastle, UK
| | | | - Alana Butler
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Benjamin J Marsland
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Trust, Newcastle, UK
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Janet E Berrington
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK.
- Newcastle Neonatal Service, Newcastle Hospitals NHS Trust, Newcastle, UK.
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5
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Kulkarni T, Majarikar S, Deshmukh M, Ananthan A, Balasubramanian H, Keil A, Patole S. Probiotic sepsis in preterm neonates-a systematic review. Eur J Pediatr 2022; 181:2249-2262. [PMID: 35348825 DOI: 10.1007/s00431-022-04452-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/22/2022] [Accepted: 03/17/2022] [Indexed: 02/05/2023]
Abstract
UNLABELLED Sepsis due to the administered probiotic strain/s is a barrier against adoption of prophylactic probiotic supplementation in preterm infants to reduce the risk of necrotising enterocolitis (NEC ≥ Stage II), all-cause mortality, late-onset sepsis, and feeding intolerance. We aimed to conduct a systematic review for reports of probiotic sepsis in preterm infants (gestation < 37 weeks). Databases including PubMed, Embase, Emcare, Cochrane Central library, and Google Scholar were searched in August 2021 and updated in Jan 2022. Probiotic sepsis was defined as positive blood/CSF culture isolating administered probiotic strain with symptoms suggestive of infection. Data collection included birth weight, gestation, comorbidities (e.g. gut surgery, NEC), presence of central venous catheters, treatment, and outcome. Literature search revealed 1569 studies. A total of 16 reports [randomised control trial (RCT): none; non-RCT: 1; case series: 8; case report: 7] involving 32 preterm infants with probiotic sepsis were included after exclusions for various reasons. Majority of the cases were born < 32 weeks' gestation. Bifidobacterium (N = 19) was the most commonly isolated organism followed by Lactobacillus (N = 10), and Saccharomyces (N = 3). A total of 25/32 cases were confirmed to be due to the administered probiotic strain on full genomic analysis. Two studies reported one neonatal death each. Twelve neonates had comorbidities. Majority were treated with antibiotics (29/32) whereas others (3/32) required antifungal treatment. CONCLUSION Probiotics sepsis is relatively an uncommon event in preterm infants. Majority of the cases recovered after antibiotic or antifungal treatment. The importance of optimal surveillance and treatment of probiotic sepsis and research towards alternatives to probiotics (e.g. postbiotics) is emphasised. WHAT IS KNOWN • Probiotics have been shown to reduce necrotising enterocolitis, late-onset sepsis, all-cause mortality, and time to reach full enteral feeds in preterm infants. • Despite the evidence, use of probiotics is not universal due to concerns regarding probiotic-associated sepsis in preterm infants. WHAT IS NEW • This comprehensive systematic review showed that probiotic sepsis is a relatively rare phenomenon in preterm infants. • All except one case where the diagnosis was uncertain recovered after antimicrobial therapy.
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Affiliation(s)
- Tithi Kulkarni
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, WA, Australia
| | - Swati Majarikar
- Department of Neonatology, Fiona Stanley Hospital, 11 Robin Warren Drive, Perth, WA, 6150, Australia
| | - Mangesh Deshmukh
- Department of Neonatology, Fiona Stanley Hospital, 11 Robin Warren Drive, Perth, WA, 6150, Australia.
- Department of Neonatology, St. John of God Hospital Subiaco, Perth, WA, Australia.
| | - Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Anthony Keil
- PathWest Laboratory Medicine Western Australia, Perth, WA, Australia
- King Edward Memorial Hospital, Perth, WA, Australia
| | - Sanjay Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
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6
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Plummer EL, Danielewski JA, Garland SM, Su J, Jacobs SE, Murray GL. The effect of probiotic supplementation on the gut microbiota of preterm infants. J Med Microbiol 2021; 70. [PMID: 34431764 PMCID: PMC8513625 DOI: 10.1099/jmm.0.001403] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Probiotic supplementation of preterm infants may prevent serious morbidities associated with prematurity.Aim. To investigate the impact of probiotic supplementation on the gut microbiota and determine factors associated with detection of probiotic species in the infant gut.Hypothesis/Gap Statement. Probiotic supplementation increases the long-term colonization of probiotic species in the gut of preterm infants.Methodology. Longitudinal stool samples were collected from a cohort of very preterm infants participating in a blinded randomized controlled trial investigating the impact of probiotic supplementation (containing Bifidobacterium longum subsp. infantis BB-02, Bifidobacterium animalis subsp. lactis BB-12 and Streptococcus thermophilus TH-4) for prevention of late-onset sepsis. The presence of B. longum subsp. infantis, B. animalis subsp. lactis and S. thermophilus was determined for up to 23 months after supplementation ended using real-time PCR. Logistic regression was used to investigate the impact of probiotic supplementation on the presence of each species.Results. Detection of B. longum subsp. infantis [odds ratio (OR): 53.1; 95 % confidence interval (CI): 35.6-79.1; P < 0.001], B. animalis subsp. lactis (OR: 89.1; 95 % CI: 59.0-134.5; P < 0.001) and S. thermophilus (OR: 5.66; 95 % CI: 4.35-7.37; P < 0.001) was increased during the supplementation period in infants receiving probiotic supplementation. Post-supplementation, probiotic-supplemented infants had increased detection of B. longum subsp. infantis (OR: 2.53; 95 % CI: 1.64-3.90; P < 0.001) and B. animalis subsp. lactis (OR: 1.59; 95 % CI: 1.05-2.41; P=0.030). Commencing probiotic supplementation before 5 days from birth was associated with increased detection of the probiotic species over the study period (B. longum subsp. infantis, OR: 1.20; B. animalis subsp. lactis, OR: 1.28; S. thermophilus, OR: 1.45).Conclusion. Probiotic supplementation with B. longum subsp. infantis BB-02, B. animalis subsp. lactis BB-12 and S. thermophilus TH-4 enhances the presence of probiotic species in the gut microbiota of very preterm infants during and after supplementation. Commencing probiotic supplementation shortly after birth may be important for improving the long-term colonization of probiotic species.
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Affiliation(s)
- Erica L Plummer
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jennifer A Danielewski
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Suzanne M Garland
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
| | - Jenny Su
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Susan E Jacobs
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Gerald L Murray
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
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7
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Abstract
Probiotic products in the United States are available for use in the general category of dietary supplements, bypassing the rigor of the US Food and Drug Administration (FDA) approval process in safety, efficacy, and manufacturing standards. As a result, currently available probiotics lack FDA-approved drug labeling and cannot be marketed to treat or prevent disease in preterm infants, including necrotizing enterocolitis and late-onset sepsis. Despite lack of availability of a pharmaceutical-grade product, the number of preterm infants receiving probiotics in the United States and Canada is steadily increasing. According to recent reports from large collaborative databases in the United States, approximately 10% of extremely low gestational age neonates receive a probiotic preparation during their stay in the NICU, with wide variation in practice among units. In sum, more than 10 000 preterm infants have been enrolled in randomized clinical trials of probiotic supplementation worldwide. Methodologic differences among study protocols included different strains and combinations of therapy, masking of trials, and a priori definitions of the primary outcome measure. Large meta-analyses of these trials have demonstrated the efficacy of multiple-strain probiotics in reducing necrotizing enterocolitis and all-cause mortality, whereas the efficacy of single-strain probiotic preparations is less certain. In the absence of an appropriate medical-grade product in the United States, dietary supplement-grade probiotics, some of which have been the subject of recent recalls for contamination, are being prescribed. Given the lack of FDA-regulated pharmaceutical-grade products in the United States, conflicting data on safety and efficacy, and potential for harm in a highly vulnerable population, current evidence does not support the routine, universal administration of probiotics to preterm infants, particularly those with a birth weight of <1000 g.
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Affiliation(s)
- Brenda Poindexter
- Children's Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
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8
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Westaway JAF, Huerlimann R, Miller CM, Kandasamy Y, Norton R, Rudd D. Methods for exploring the faecal microbiome of premature infants: a review. Matern Health Neonatol Perinatol 2021; 7:11. [PMID: 33685524 PMCID: PMC7941982 DOI: 10.1186/s40748-021-00131-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/01/2021] [Indexed: 12/13/2022] Open
Abstract
The premature infant gut microbiome plays an important part in infant health and development, and recognition of the implications of microbial dysbiosis in premature infants has prompted significant research into these issues. The approaches to designing investigations into microbial populations are many and varied, each with its own benefits and limitations. The technique used can influence results, contributing to heterogeneity across studies. This review aimed to describe the most common techniques used in researching the preterm infant microbiome, detailing their various limitations. The objective was to provide those entering the field with a broad understanding of available methodologies, so that the likely effects of their use can be factored into literature interpretation and future study design. We found that although many techniques are used for characterising the premature infant microbiome, 16S rRNA short amplicon sequencing is the most common. 16S rRNA short amplicon sequencing has several benefits, including high accuracy, discoverability and high throughput capacity. However, this technique has limitations. Each stage of the protocol offers opportunities for the injection of bias. Bias can contribute to variability between studies using 16S rRNA high throughout sequencing. Thus, we recommend that the interpretation of previous results and future study design be given careful consideration.
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Affiliation(s)
- Jacob A F Westaway
- James Cook University, 1 McGregor Road, Smithfield, QLD, 4878, Australia.
| | - Roger Huerlimann
- James Cook University, 1 James Cook Dr, Douglas, QLD, 4811, Australia
| | - Catherine M Miller
- James Cook University, 1 McGregor Road, Smithfield, QLD, 4878, Australia
| | - Yoga Kandasamy
- Townsville University Hospital, 100 Angus Smith Dr, Douglas, QLD, 4814, Australia
| | - Robert Norton
- Pathology Queensland, 100 Angus Smith Dr, Douglas, QLD, 4814, Australia
| | - Donna Rudd
- James Cook University, 1 James Cook Dr, Douglas, QLD, 4811, Australia
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9
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Bajorek S, Duar RM, Corrigan M, Matrone C, Winn KA, Norman S, Mitchell RD, Cagney O, Aksenov AA, Melnik AV, Kopylova E, Perez J. B. infantis EVC001 Is Well-Tolerated and Improves Human Milk Oligosaccharide Utilization in Preterm Infants in the Neonatal Intensive Care Unit. Front Pediatr 2021; 9:795970. [PMID: 35071138 PMCID: PMC8767116 DOI: 10.3389/fped.2021.795970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/07/2021] [Indexed: 12/30/2022] Open
Abstract
Not all infants carry specialized gut microbes, meaning they cannot digest human milk oligosaccharides and therefore do not receive complete benefits from human milk. B. infantis EVC001 is equipped to convert the full array of complex oligosaccharides into compounds usable by the infant, making it an ideal candidate to stabilize gut function and improve nutrition in preterm infants. A prospective, open-label study design was used to evaluate the tolerability of B. infantis EVC001 and its effects on the fecal microbiota in preterm infants in a Neonatal Intensive Care Unit. Thirty preterm infants <1,500 g and/or <33 weeks gestation at birth were divided into two matched groups, and control infants were enrolled and discharged prior to enrolling EVC001 infants to prevent cross-colonization of B. infantis: (1) fifteen control infants received no EVC001, and (2) fifteen infants received once-daily feedings of B. infantis EVC001 (8.0 x 109 CFU) in MCT oil. Clinical information regarding medications, growth, nutrition, gastrointestinal events, diagnoses, and procedures was collected throughout admission. Infant stool samples were collected at baseline, Study Days 14 and 28, and 34-, 36-, and 38-weeks of gestation. Taxonomic composition of the fecal microbiota, functional microbiota analysis, B. infantis, and human milk oligosaccharides (HMOs) in the stool were determined or quantified using 16S rRNA gene sequencing, metagenomic sequencing, qPCR, and mass spectrometry, respectively. No adverse events or tolerability issues related to EVC001 were reported. Control infants had no detectable levels of B. infantis. EVC001 infants achieved high levels of B. infantis (mean = 9.7 Log10 CFU/μg fecal DNA) by Study Day 14, correlating with less fecal HMOs (ρ = -0.83, P < 0.0001), indicating better HMO utilization in the gut. In this study, B. infantis EVC001 was shown to be safe, well-tolerated, and efficient in colonizing the preterm infant gut and able to increase the abundance of bifidobacteria capable of metabolizing HMOs, resulting in significantly improved utilization of human milk. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03939546, identifier: NCT03939546.
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Affiliation(s)
- Sarah Bajorek
- St. Mary's Hospital, Grand Junction, CO, United States.,Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States
| | | | - Maxwell Corrigan
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States
| | - Christa Matrone
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States
| | - Kathryn A Winn
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States
| | - Susan Norman
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States
| | | | - Orla Cagney
- Evolve BioSystems Inc., Davis, CA, United States
| | - Alexander A Aksenov
- Department of Chemistry, University of Connecticut, Storrs, CT, United States.,Arome Science Inc., Farmington, CT, United States.,Clarity Genomics Inc., San Diego, CA, United States
| | - Alexey V Melnik
- Department of Chemistry, University of Connecticut, Storrs, CT, United States.,Arome Science Inc., Farmington, CT, United States.,Clarity Genomics Inc., San Diego, CA, United States
| | - Evguenia Kopylova
- Arome Science Inc., Farmington, CT, United States.,Clarity Genomics Inc., San Diego, CA, United States
| | - Jose Perez
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, FL, United States.,Seattle Children's Hospital, University of Washington, Seattle, WA, United States
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10
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Alcon-Giner C, Dalby MJ, Caim S, Ketskemety J, Shaw A, Sim K, Lawson MA, Kiu R, Leclaire C, Chalklen L, Kujawska M, Mitra S, Fardus-Reid F, Belteki G, McColl K, Swann JR, Kroll JS, Clarke P, Hall LJ. Microbiota Supplementation with Bifidobacterium and Lactobacillus Modifies the Preterm Infant Gut Microbiota and Metabolome: An Observational Study. CELL REPORTS MEDICINE 2020; 1:100077. [PMID: 32904427 PMCID: PMC7453906 DOI: 10.1016/j.xcrm.2020.100077] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/28/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Abstract
Supplementation with members of the early-life microbiota as “probiotics” is increasingly used in attempts to beneficially manipulate the preterm infant gut microbiota. We performed a large observational longitudinal study comprising two preterm groups: 101 infants orally supplemented with Bifidobacterium and Lactobacillus (Bif/Lacto) and 133 infants non-supplemented (control) matched by age, sex, and delivery method. 16S rRNA gene profiling on fecal samples (n = 592) showed a predominance of Bifidobacterium and a lower abundance of pathobionts in the Bif/Lacto group. Metabolomic analysis showed higher fecal acetate and lactate and a lower fecal pH in the Bif/Lacto group compared to the control group. Fecal acetate positively correlated with relative abundance of Bifidobacterium, consistent with the ability of the supplemented Bifidobacterium strain to metabolize human milk oligosaccharides into acetate. This study demonstrates that microbiota supplementation is associated with a Bifidobacterium-dominated preterm microbiota and gastrointestinal environment more closely resembling that of full-term infants. Bifidobacterium dominates the gut microbiota in supplemented preterm infants Supplemented preterm infants have lower abundance of potential pathobionts Metabolomic analysis show higher fecal acetate and lower pH in supplemented infants In vitro and genomic analysis confirm HMO metabolism in Bifidobacterium supplement
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Affiliation(s)
- Cristina Alcon-Giner
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Matthew J. Dalby
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Shabhonam Caim
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Jennifer Ketskemety
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Alex Shaw
- Department of Medicine, Section of Pediatrics, Imperial College London, London, UK
| | - Kathleen Sim
- Department of Medicine, Section of Pediatrics, Imperial College London, London, UK
| | - Melissa A.E. Lawson
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Raymond Kiu
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Charlotte Leclaire
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Lisa Chalklen
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Magdalena Kujawska
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Suparna Mitra
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Fahmina Fardus-Reid
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Gustav Belteki
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Katherine McColl
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospital, Norwich, UK
| | - Jonathan R. Swann
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J. Simon Kroll
- Department of Medicine, Section of Pediatrics, Imperial College London, London, UK
| | - Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lindsay J. Hall
- Gut Microbes & Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Chair of Intestinal Microbiome, School of Life Sciences, Technical University of Munich, Freising, Germany
- ZIEL – Institute for Food & Health, Technical University of Munich, Freising, Germany
- Corresponding author
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11
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Probiotics and Preterm Infants: A Position Paper by the European Society for Paediatric Gastroenterology Hepatology and Nutrition Committee on Nutrition and the European Society for Paediatric Gastroenterology Hepatology and Nutrition Working Group for Probiotics and Prebiotics. J Pediatr Gastroenterol Nutr 2020; 70:664-680. [PMID: 32332478 DOI: 10.1097/mpg.0000000000002655] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
More than 10,000 preterm infants have participated in randomised controlled trials on probiotics worldwide, suggesting that probiotics in general could reduce rates of necrotising enterocolitis (NEC), sepsis, and mortality. Answers to relevant clinical questions as to which strain to use, at what dosage, and how long to supplement are, however, not available. On the other hand, an increasing number of commercial products containing probiotics are available from sometimes suboptimal quality. Also, a large number of units around the world are routinely offering probiotic supplementation as the standard of care despite lacking solid evidence. Our recent network meta-analysis identified probiotic strains with greatest efficacy regarding relevant clinical outcomes for preterm neonates. Efficacy in reducing mortality and morbidity was found for only a minority of the studied strains or combinations. In the present position paper, we aim to provide advice, which specific strains might potentially be used and which strains should not be used. In addition, we aim to address safety issues of probiotic supplementation to preterm infants, who have reduced immunological capacities and occasional indwelling catheters. For example, quality reassurance of the probiotic product is essential, probiotic strains should be devoid of transferable antibiotic resistance genes, and local microbiologists should be able to routinely detect probiotic sepsis. Provided all safety issues are met, there is currently a conditional recommendation (with low certainty of evidence) to provide either Lactobacillus rhamnosus GG ATCC53103 or the combination of Bifidobacterium infantis Bb-02, Bifidobacterium lactis Bb-12, and Streptococcus thermophilus TH-4 in order to reduce NEC rates.
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12
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Abstract
PURPOSE OF REVIEW Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among premature neonates. Although randomized trials have shown that probiotics may be efficacious in the prevention of NEC, their use has not been universally adopted in the neonatal intensive care unit (NICU). Caveats regarding routine probiotic supplementation for the prevention of NEC are summarized in this review. RECENT FINDINGS Accumulating evidence indicates that prophylactic probiotic supplementation in preterm infants can reduce the incidence of NEC. However, substantial knowledge gaps, regulatory issues, and implementation challenges should be addressed before probiotics are introduced as standard of care for all preterm neonates. Limitations of published trial data have made it challenging to define regimens that optimize efficacy and safety in specific patient subgroups. Moreover, the current probiotic market lacks rigorous regulatory oversight, which could raise concerns about the quality and safety of probiotic products. Finally, implementation pitfalls include risks of cross-colonization and resource requirements to monitor and mitigate potential adverse events. SUMMARY Probiotics have shown promise in the prevention of NEC. However, there is insufficient evidence to guide the selection of optimal regimens. Furthermore, issues related to regulatory and institutional oversight should be addressed before supplementation is routinely implemented in NICUs.
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Plummer EL, Bulach DM, Murray GL, Jacobs SE, Tabrizi SN, Garland SM. Gut microbiota of preterm infants supplemented with probiotics: sub-study of the ProPrems trial. BMC Microbiol 2018; 18:184. [PMID: 30424728 PMCID: PMC6234596 DOI: 10.1186/s12866-018-1326-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/25/2018] [Indexed: 12/15/2022] Open
Abstract
Background The ProPrems trial, a multi-center, double-blind, placebo-controlled randomized trial, previously reported a 54% reduction in necrotizing enterocolitis (NEC) of Bell stage 2 or more from 4.4 to 2.0% in 1099 infants born before 32 completed weeks’ gestation and weighing < 1500 g, receiving probiotic supplementation (with Bifidobacterium longum subsp. infantis BB-02, Streptococcus thermophilus TH-4 and Bifidobacterium animalis subsp. lactis BB-12). This sub-study investigated the effect of probiotic supplementation on the gut microbiota in a cohort of very preterm infants in ProPrems. Results Bifidobacterium was found in higher abundance in infants who received the probiotics (AOR 17.22; 95% CI, 3.49–84.99, p < 0.001) as compared to the placebo group, and Enterococcus was reduced in infants receiving the probiotic during the supplementation period (AOR 0.27; 95% CI, 0.09–0.82, p = 0.02). Conclusion Probiotic supplementation with BB-02, TH-4 and BB-12 from soon after birth increased the abundance of Bifidobacterium in the gut microbiota of very preterm infants. Increased abundance of Bifidobacterium soon after birth may be associated with reducing the risk of NEC in very preterm infants. Electronic supplementary material The online version of this article (10.1186/s12866-018-1326-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erica L Plummer
- The Royal Women's Hospital, Parkville, VIC, 3052, Australia. .,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, 3052, Australia.
| | - Dieter M Bulach
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, VIC, 3800, Australia.,The University of Melbourne, Parkville, VIC, 3050, Australia.,Victorian Life Sciences Computation Initiative, The University of Melbourne, Parkville Campus, LAB-14, 700 Swanston St, Carlton, VIC, 3053, Australia
| | - Gerald L Murray
- The Royal Women's Hospital, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, 3052, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, VIC, 3800, Australia
| | - Susan E Jacobs
- The Royal Women's Hospital, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, 3052, Australia.,The University of Melbourne, Parkville, VIC, 3050, Australia
| | - Sepehr N Tabrizi
- The Royal Women's Hospital, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, 3052, Australia.,The University of Melbourne, Parkville, VIC, 3050, Australia.,The Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia
| | - Suzanne M Garland
- The Royal Women's Hospital, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, 3052, Australia.,The University of Melbourne, Parkville, VIC, 3050, Australia.,The Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia
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14
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Aceti A, Beghetti I, Maggio L, Martini S, Faldella G, Corvaglia L. Filling the Gaps: Current Research Directions for a Rational Use of Probiotics in Preterm Infants. Nutrients 2018; 10:E1472. [PMID: 30308999 PMCID: PMC6213418 DOI: 10.3390/nu10101472] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 02/06/2023] Open
Abstract
The use of probiotics among very low-birth-weight infants is constantly increasing, as probiotics are believed to reduce the incidence of severe diseases such as necrotizing enterocolitis and late-onset sepsis and to improve feeding tolerance. However, despite the enthusiasm towards these products in neonatal medicine, theoretical knowledge and clinical applications still need to be improved. The purpose of this review is to give an overview of the most important gaps in the current literature about potential uses of probiotics in preterm infants, highlighting promising directions for future research. Specifically, further well-designed studies should aim at clarifying the impact of the type of feeding (mother's milk, donor milk, and formula) on the relationship between probiotic supplementation and clinical outcome. Moreover, future research is needed to provide solid evidence about the potential greater efficacy of multi-strain probiotics compared to single-strain products. Safety issues should also be addressed properly, by exploring the potential of paraprobiotics and risks connected to antibiotic resistance in preterm infants. Last, in light of increasing commercial and public interests, the long-term effect of routine consumption of probiotics in such a vulnerable population should be also evaluated.
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Affiliation(s)
- Arianna Aceti
- Neonatal Intensive Care Unit, AOU Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy.
| | - Isadora Beghetti
- Neonatal Intensive Care Unit, AOU Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy.
| | - Luca Maggio
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy.
| | - Silvia Martini
- Neonatal Intensive Care Unit, AOU Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy.
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, AOU Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy.
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, AOU Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy.
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15
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Gengaimuthu K. The Cross Contamination (Cross Colonization) Phenomenon of Probiotic Use in Neonatal Intensive Care Units: Putative Mechanisms and Clinical and Research Implications. Cureus 2018; 10:e2691. [PMID: 30050746 PMCID: PMC6059533 DOI: 10.7759/cureus.2691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/24/2018] [Indexed: 01/21/2023] Open
Abstract
In studies of probiotic use in neonates the phenomenon of cross contamination (cross colonization) of the control group neonates with the probiotics administered to the study group was observed and a hypothetical reanalysis of the presented data after statistically controlling this phenomenon unveils significant benefits resulting from probiotic therapy. This article discusses the putative pathogenesis of this phenomenon and its clinical and research implications.
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16
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Costeloe K, Bowler U, Brocklehurst P, Hardy P, Heal P, Juszczak E, King A, Panton N, Stacey F, Whiley A, Wilks M, Millar MR. A randomised controlled trial of the probiotic Bifidobacterium breve BBG-001 in preterm babies to prevent sepsis, necrotising enterocolitis and death: the Probiotics in Preterm infantS (PiPS) trial. Health Technol Assess 2018; 20:1-194. [PMID: 27594381 DOI: 10.3310/hta20660] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Necrotising enterocolitis (NEC) and late-onset sepsis remain important causes of death and morbidity in preterm babies. Probiotic administration might strengthen intestinal barrier function and provide protection; this is supported by published meta-analyses, but there is a lack of large well-designed trials. OBJECTIVE To test the use of the probiotic Bifidobacterium breve strain BBG-001 to prevent NEC, late-onset sepsis and death in preterm babies while monitoring probiotic colonisation of participants. DESIGN Double-blind, randomised, placebo-controlled trial. SETTING Recruitment was carried out in 24 hospitals, and the randomisation programme used a minimisation algorithm. Parents, clinicians and outcome assessors were blinded to the allocation. PARTICIPANTS Babies born between 23 and 30 weeks' gestation and randomised within 48 hours of birth. Exclusions included life-threatening or any gastrointestinal malformation detected within 48 hours of birth and no realistic chance of survival. INTERVENTIONS Active intervention: 1 ml of B. breve BBG-001 in one-eighth-strength infant formula Neocate(®) (Nutricia Ltd, Trowbridge, UK), (6.7 × 10(7) to 6.7 × 10(9) colony-forming units) per dose administered enterally. Placebo: 1 ml of one-eighth-strength infant formula Neocate. Started as soon as practicable and continued daily until 36 weeks' postmenstrual age. MAIN OUTCOME MEASURES Primary outcomes were an episode of bloodstream infection, with any organism other than a skin commensal, in any baby between 72 hours and 46 weeks' postmenstrual age; an episode of NEC Bell stage ≥ 2 in any baby; and death before discharge from hospital. Secondary outcomes included stool colonisation with B. breve. RESULTS In total, 654 babies were allocated to receive probiotic and 661 to receive placebo over 37 months from July 2010. Five babies were withdrawn; 650 babies from the probiotic group and 660 from the placebo group were included in the primary analysis. Baseline characteristics were well balanced. There was no evidence of benefit for the primary outcomes {sepsis: 11.2% vs. 11.7% [adjusted relative risk (RR) 0.97, 95% confidence interval (CI) 0.73 to 1.29]; NEC Bell stage ≥ 2: 9.4% vs. 10.0% [adjusted RR 0.93, 95% CI 0.68 to 1.27]; and death: 8.3% vs. 8.5% [adjusted RR 0.93, 95% CI 0.67 to 1.30]}. B. breve colonisation status was available for 1186 (94%) survivors at 2 weeks' postnatal age, of whom 724 (61%) were positive: 85% of the probiotic group and 37% of the placebo group. There were no differences for subgroup analyses by minimisation criteria and by stool colonisation with B. breve at 2 weeks. No harms associated with the interventions were reported. LIMITATIONS Cross-colonisation of the placebo arm could have reduced statistical power and confounded results; analyses suggest that this did not happen. CONCLUSIONS This is the largest trial to date of a probiotic intervention. It shows no evidence of benefit and does not support routine use of probiotics for preterm infants. FUTURE WORK RECOMMENDATIONS The increasing understanding of the pathogenesis of NEC and sepsis will inform the choice of probiotics for testing and better define the target population. Future Phase III trials should incorporate monitoring of the quality and viability of the intervention and colonisation rates of participants; cluster design should be considered. TRIAL REGISTRATION Current Controlled Trials ISRCTN05511098 and EudraCT 2006-003445-17. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kate Costeloe
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Homerton University Hospital NHS Foundation Trust, London, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.,Institute for Women's Health, University College London, London, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Paul Heal
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Andy King
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Nicola Panton
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Fiona Stacey
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Homerton University Hospital NHS Foundation Trust, London, UK
| | - Angela Whiley
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Wilks
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
| | - Michael R Millar
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
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17
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Meyer MP, Alexander T. Reduction in necrotizing enterocolitis and improved outcomes in preterm infants following routine supplementation with Lactobacillus GG in combination with bovine lactoferrin. J Neonatal Perinatal Med 2018; 10:249-255. [PMID: 28854514 DOI: 10.3233/npm-16130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preterm infants remain at high risk of adverse outcomes following necrotizing enterocolitis (NEC) and late onset sepsis (LOS). Meta-analysis of randomized trials has indicated a reduction in severe NEC following use of probiotics and bovine lactoferrin (LF). Overall, however, uncertainty remains over which probiotic, or combination to use. The aim of this study was to compare the incidence of severe NEC and LOS before and after routine supplementation with Lactobacillus GG (LGG) and LF. METHODS In this retrospective cohort study, infants <32 weeks or <1500 g routinely received LGG and 100 mg lactoferrin daily from 2011 -2015 were compared with similar infants born from 2004-2008. Cases of NEC were Bell stage 2 or greater and LOS was blood or spinal fluid culture positive after 48 hrs of age. RESULTS We noted a marked decline in the incidence of NEC from 3% to 1% with a RR of 0.29 (CI 0.1-0.9) and a number needed to benefit of 50. The cost of preventing one case of NEC was estimated to be NZ $2800, considerably lower than the cost of treatment. LOS rates were not significantly different. There was a decrease in retinopathy treatment rates. During the period there was one case of LGG sepsis in a 23 week gestation infant with abdominal pathology and one infant developed NEC after stopping prophylaxis. CONCLUSION The rates of severe NEC was markedly reduced following prophylaxis. The case of LGG sepsis indicates caution is required in extremely preterm infants.
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Affiliation(s)
- Michael P Meyer
- Neonatal Unit Kidz First Paediatrics, Middlemore Hospital, Otahuhu, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Grafton Auckland, New Zealand
| | - Tanith Alexander
- Dietetics, Allied Health, Middlemore Hospital, Otahuhu, Auckland, New Zealand
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18
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Embleton ND, Berrington JE, Dorling J, Ewer AK, Juszczak E, Kirby JA, Lamb CA, Lanyon CV, McGuire W, Probert CS, Rushton SP, Shirley MD, Stewart CJ, Cummings SP. Mechanisms Affecting the Gut of Preterm Infants in Enteral Feeding Trials. Front Nutr 2017; 4:14. [PMID: 28534028 PMCID: PMC5420562 DOI: 10.3389/fnut.2017.00014] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/18/2017] [Indexed: 12/20/2022] Open
Abstract
Large randomized controlled trials (RCTs) in preterm infants offer unique opportunities for mechanistic evaluation of the risk factors leading to serious diseases, as well as the actions of interventions designed to prevent them. Necrotizing enterocolitis (NEC) a serious inflammatory gut condition and late-onset sepsis (LOS) are common feeding and nutrition-related problems that may cause death or serious long-term morbidity and are key outcomes in two current UK National Institutes for Health Research (NIHR) trials. Speed of increasing milk feeds trial (SIFT) randomized preterm infants to different rates of increases in milk feeds with a primary outcome of survival without disability at 2 years corrected age. Enteral lactoferrin in neonates (ELFIN) randomizes infants to supplemental enteral lactoferrin or placebo with a primary outcome of LOS. This is a protocol for the mechanisms affecting the gut of preterm infants in enteral feeding trials (MAGPIE) study and is funded by the UK NIHR Efficacy and Mechanistic Evaluation programme. MAGPIE will recruit ~480 preterm infants who were enrolled in SIFT or ELFIN. Participation in MAGPIE does not change the main trial protocols and uses non-invasive sampling of stool and urine, along with any residual resected gut tissue if infants required surgery. Trial interventions may involve effects on gut microbes, metabolites (e.g., short-chain fatty acids), and aspects of host immune function. Current hypotheses suggest that NEC and/or LOS are due to a dysregulated immune system in the context of gut dysbiosis, but mechanisms have not been systematically studied within large RCTs. Microbiomic analysis will use next-generation sequencing, and metabolites will be assessed by mass spectrometry to detect volatile organic and other compounds produced by microbes or the host. We will explore differences between disease cases and controls, as well as exploring the actions of trial interventions. Impacts of this research are multiple: translation of knowledge of mechanisms promoting gut health may explain outcomes or suggest alternate strategies to improve health. Results may identify new non-invasive diagnostic or monitoring techniques, preventative or treatment strategies for NEC or LOS, or provide data useful for risk stratification in future studies. Mechanistic evaluation might be especially informative where there are not clear effects on the primary outcome (ISRCTN 12554594).
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Affiliation(s)
- Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Janet E Berrington
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jon Dorling
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew K Ewer
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, Birmingham University, Birmingham, UK
| | | | - John A Kirby
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher A Lamb
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Clare V Lanyon
- Department for Biomedical Sciences, School of Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Christopher S Probert
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Mark D Shirley
- School of Biology, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Department for Biomedical Sciences, School of Life Sciences, Northumbria University, Newcastle upon Tyne, UK.,Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
| | - Stephen P Cummings
- School of Science and Engineering, Teesside University, Middlesbrough, UK
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19
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Bifidobacterium bifidum OLB6378 Simultaneously Enhances Systemic and Mucosal Humoral Immunity in Low Birth Weight Infants: A Non-Randomized Study. Nutrients 2017; 9:nu9030195. [PMID: 28245626 PMCID: PMC5372858 DOI: 10.3390/nu9030195] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/10/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022] Open
Abstract
Probiotic supplementation has been part of the discussion on methods to enhance humoral immunity. Administration of Bifidobacterium bifidum OLB6378 (OLB6378) reduced the incidence of late-onset sepsis in infants. In this non-randomized study, we aimed to determine the effect of administration of live OLB6378 on infants' humoral immunity. Secondly, we tried to elucidate whether similar effects would be observed with administration of non-live OLB6378. Low birth weight (LBW) infants weighing 1500-2500 g were divided into three groups: Group N (no intervention), Group L (administered live OLB6378 concentrate), and Group H (administered non-live OLB6378 concentrate). The interventions were started within 48 h after birth and continued until six months of age. Serum immunoglobulin G (IgG) levels (IgG at one month/IgG at birth) were significantly higher in Group L than in Group N (p < 0.01). Group H exhibited significantly higher serum IgG levels (p < 0.01) at one month of age and significantly higher intestinal secretory immunoglobulin A (SIgA) levels (p < 0.05) at one and two months of age than Group N. No difference was observed in the mortality or morbidity between groups. Thus, OLB6378 administration in LBW infants enhanced humoral immunity, and non-live OLB6378, which is more useful as a food ingredient, showed a more marked effect than the viable bacteria.
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20
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Petersen SM, Greisen G, Krogfelt KA. Nasogastric feeding tubes from a neonatal department yield high concentrations of potentially pathogenic bacteria- even 1 d after insertion. Pediatr Res 2016; 80:395-400. [PMID: 27064248 DOI: 10.1038/pr.2016.86] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preterm infants are vulnerable to pathogens and at risk of developing necrotizing enterocolitis (NEC) or sepsis. Nasogastric feeding tubes (NG-tubes) might contaminate feeds given through them due to biofilm formation. We wanted to determine if there is a rationale in replacing NG-tubes more often to reduce contamination. METHODS We conducted an observational study of used NG-tubes from a tertiary neonatal department. After removal, we flushed a 1-ml saline solution through the tube, determined the density of bacteria by culture, and related it to the duration of use and any probiotic administration through the tube. RESULTS Out of the 94 NG-tubes, 89% yielded more than 1,000 colony-forming units (CFU)/ml bacteria, and 55% yielded the potentially pathogenic Enterobacteriaceae and/or Staphylococcus aureus. The mean concentration in the yield was 5.3 (SD: 2.1, maximum 9.4) log10CFU/ml. Neither the presence of contamination nor the density was associated with the time the NG-tube had been in use. Probiotic administration did not protect against contamination. CONCLUSION NG-tubes yielded high densities of bacteria even within the first day of use. Further studies are needed to determine if changing the NG-tubes between meals or once a day will make a positive impact on tube contamination and clinical parameters.
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Affiliation(s)
- Sandra Meinich Petersen
- Department of Neonatology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Karen Angeliki Krogfelt
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
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Probiotics for prevention of necrotizing enterocolitis and sepsis in preterm infants. Curr Opin Infect Dis 2016; 29:256-61. [DOI: 10.1097/qco.0000000000000269] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Patole SK, Rao SC, Keil AD, Nathan EA, Doherty DA, Simmer KN. Benefits of Bifidobacterium breve M-16V Supplementation in Preterm Neonates - A Retrospective Cohort Study. PLoS One 2016; 11:e0150775. [PMID: 26953798 PMCID: PMC4783036 DOI: 10.1371/journal.pone.0150775] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/18/2016] [Indexed: 01/08/2023] Open
Abstract
Background Systematic reviews of randomised controlled trials report that probiotics reduce the risk of necrotising enterocolitis (NEC) in preterm neonates. Aim To determine whether routine probiotic supplementation (RPS) to preterm neonates would reduce the incidence of NEC. Methods The incidence of NEC ≥ Stage II and all-cause mortality was compared for an equal period of 24 months ‘before’ (Epoch 1) and ‘after’ (Epoch 2) RPS with Bifidobacterium breve M-16V in neonates <34 weeks. Multivariate logistic regression analysis was conducted to adjust for relevant confounders. Results A total of 1755 neonates (Epoch I vs. II: 835 vs. 920) with comparable gestation and birth weights were admitted. There was a significant reduction in NEC ≥ Stage II: 3% vs. 1%, adjusted odds ratio (aOR) = 0.43 (95%CI: 0.21–0.87); ‘NEC ≥ Stage II or all-cause mortality’: 9% vs. 5%, aOR = 0.53 (95%CI: 0.32–0.88); but not all-cause mortality alone: 7% vs. 4%, aOR = 0.58 (95% CI: 0.31–1.06) in Epoch II. The benefits in neonates <28 weeks did not reach statistical significance: NEC ≥ Stage II: 6% vs. 3%, aOR 0.51 (95%CI: 0.20–1.27), ‘NEC ≥ Stage II or all-cause mortality’, 21% vs. 14%, aOR = 0.59 (95%CI: 0.29–1.18); all-cause mortality: 17% vs. 11%, aOR = 0.63 (95%CI: 0.28–1.41). There was no probiotic sepsis. Conclusion RPS with Bifidobacterium breve M-16V was associated with decreased NEC≥ Stage II and ‘NEC≥ Stage II or all-cause mortality’ in neonates <34 weeks. Large sample size is required to assess the potential benefits of RPS in neonates <28 weeks.
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Affiliation(s)
- Sanjay K. Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, Australia
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
- * E-mail:
| | - Shripada C. Rao
- Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Australia
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Anthony D. Keil
- PathWest Laboratory Medicine Western Australia, Perth, Australia
| | - Elizabeth A. Nathan
- Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Perth, Australia
- School of Women's and Infants' Health, University of Western Australia, Perth, Australia
| | - Dorota A. Doherty
- Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Perth, Australia
- School of Women's and Infants' Health, University of Western Australia, Perth, Australia
| | - Karen N. Simmer
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, Australia
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
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Vongbhavit K, Underwood MA. Prevention of Necrotizing Enterocolitis Through Manipulation of the Intestinal Microbiota of the Premature Infant. Clin Ther 2016; 38:716-32. [PMID: 26872618 DOI: 10.1016/j.clinthera.2016.01.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/30/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE In spite of four decades of research, necrotizing enterocolitis (NEC) remains the most common gastrointestinal complication in premature infants with high mortality and long-term morbidity. The composition of the intestinal microbiota of the premature infant differs dramatically from that of the healthy term infant and appears to be an important risk factor for NEC. METHODS We review the evidence of an association between intestinal dysbiosis and NEC and summarize published English language clinical trials and cohort studies involving attempts to manipulate the intestinal microbiota in premature infants. FINDINGS Promising NEC prevention strategies that alter the intestinal microbiota include probiotics, prebiotics, synbiotics, lacteroferrin, and human milk feeding. IMPLICATIONS Shaping the intestinal microbiota of the premature infant through human milk feeding and dietary supplements decreases the risk of NEC. Further studies to identify the ideal microbial composition and the most effective combination of supplements are indicated.
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Affiliation(s)
- Kannikar Vongbhavit
- Department of Pediatrics, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornayok, Thailand; Department of Pediatrics, University of California Davis, Sacramento, California
| | - Mark A Underwood
- Department of Pediatrics, University of California Davis, Sacramento, California.
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Brecht M, Garg A, Longstaff K, Cooper C, Andersen C. Lactobacillus Sepsis following a Laparotomy in a Preterm Infant: A Note of Caution. Neonatology 2016; 109:186-9. [PMID: 26780534 DOI: 10.1159/000441965] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/27/2015] [Indexed: 11/19/2022]
Abstract
Probiotics for preterm infants have been shown to reduce the incidence of necrotising enterocolitis and all-cause mortality in a recent meta-analysis. It has been argued, however, that some of these results may not be applicable to specific subgroups, e.g. infants with a birth weight of <1,000 g. The specific role of probiotics in improving health outcomes in preterm and term infants following intestinal surgery is not well defined. We report a case of a premature infant diagnosed with late-onset sepsis due to Lactobacillus rhamnosus following a laparotomy. We review pertinent published cases. This case highlights the importance of considering preterm infants as being at a higher risk of systemic probiotic infection following intestinal surgery.
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Affiliation(s)
- Marcus Brecht
- Neonatal Intensive Care Unit, Women's and Children's Hospital, North Adelaide, S.A., Australia
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