Effect of maternal human immunodeficiency virus status on the outcome of neonates with necrotizing enterocolitis

Neonatal deaths among infants born to women living with HIV in the UK and Ireland

OBJECTIVES

To estimate the incidence of neonatal mortality among infants born to women living with HIV in the UK and Ireland in 1998-2017, describe causes of neonatal death (NND) and examine risk factors.

DESIGN

Population-based surveillance of pregnancies in diagnosed women living with HIV and their infants in the UK and Ireland.

METHODS

Estimated incidence of NND was reported for 1998-2017 and causes coded using the World Health Organization International Classification of Perinatal Mortality. Risk factor analyses used multivariable logistic regression, including delivery year, maternal origin, maternal age, delivery CD4+ cell count and viral load (VL), antiretroviral therapy (ART) at conception, preterm delivery (PTD), injecting drug use and infant sex.

RESULTS

There were 20 012 live-born infants delivered to 12 684 mothers in 19 601 pregnancies. The overall neonatal mortality rate was 4.10 per 1000 livebirths (95% confidence interval, 3.2-5.0), which was higher than that of the general population. Prematurity was the leading cause of death followed by congenital abnormality. Most NND occurred on the first day of life. ART at conception was associated with significantly reduced NND risk. In a restricted 2007-2017 analysis including VL, PTD and detectable maternal VL were associated with significantly increased NND risk.

CONCLUSIONS

The vertical transmission rate in the UK, at 3 per 1000, is now lower than the neonatal mortality rate among infants born to women living with HIV. More research is needed to investigate the complex relationship between ART, preterm delivery and neonatal death in order to improve all perinatal outcomes.

Outcomes of Neonates Requiring Neonatal Intensive Care Admission for Necrotizing Enterocolitis in a Resource-Restricted Hospital in Cape Town, South Africa

AIM

The aim of this study is to describe the 30-day mortality, neurodevelopmental outcome and composite outcome (mortality or abnormal neurodevelopmental outcome) of neonates with necrotizing enterocolitis (NEC), requiring neonatal intensive care (NICU) admission, in a resource-restricted environment.

METHODS

All neonates admitted to Tygerberg Hospital, NICU, with a presumptive diagnosis of NEC Bell stage IIB or more, over a 5-year period, were included.

RESULTS

One hundred and thirty-five neonates were included with a mean gestational age of 29 ± 2.7 weeks and mean birth weight of 1185 g ± 446 g. The 30-day mortality was 52%, neurodevelopment abnormalities occurred in 35% of survivors and adverse composite outcome in 63%. The 30-day mortality and adverse composite outcome risk were increased by small for gestational age, shock, metabolic acidosis, inotrope requirement and first feed >9 days after surgery.

CONCLUSION

In resource-restricted environments, mortality and abnormal neurodevelopmental outcome of neonates with NEC, remain high. However, outcomes are comparable with international literature. Neonates with NEC, requiring NICU admission and surgery, require neurodevelopmental follow-up.

Short-term outcomes of HIV-exposed and HIV-unexposed preterm, very low birthweight neonates: a longitudinal, hospital-based study

OBJECTIVE

To compare short-term outcomes of very low birthweight (VBLW, <1500 g) neonates by maternal HIV status.

DESIGN

Retrospective hospital-based cohort in Cape Town, South Africa.

RESULTS

Of 1579 mothers, 316 (20%) were HIV-positive; 183/316 (58%) received ≥8 weeks of antenatal antiretrovirals. HIV-exposed neonates (HIVE, vs HIV-unexposed, HIVU) had increased risk of necrotising enterocolitis (NEC; OR 1.93, 95% CI 1.27-2.92) and invasive ventilation (OR 1.35, 95% CI 1.01-1.79). Extremely low birthweight (ELBW, <1000 g) modified the HIV-exposure-mortality relationship: among ELBW neonates, HIVE vs HIVU mortality OR 1.75 (95% CI 1.13-2.69); among non-ELBW, OR 0.89 (95% CI 0.54-1.49). Antiretrovirals (≥8 vs <8 weeks/none) reduced NEC (OR 0.46, 95% CI 0.22-0.97) and invasive ventilation risks (OR 0.57, 95% CI 0.32-0.99). HIV-PCR results were available for 228/316 (72%) HIVE neonates; 11/228 (5%) tested positive.

CONCLUSIONS

Among VLBW neonates, HIV-exposure was associated with increased risk of adverse short-term outcomes; antenatal antiretrovirals were protective.

Maternal human immunodeficiency virus status and morbidity and mortality in very low birthweight infants

BACKGROUND

Human immunodeficiency virus (HIV) remains a common cause of infection in pregnant women. The effect of HIV exposure on growth, morbidity and mortality in very low-birthweight infants (VLBWI) is under-reported.

AIM

To determine anthropometry at birth, morbidity during hospital stay and mortality at hospital discharge of VLBWI stratified according to HIV-exposure in a tertiary public government hospital in Johannesburg, South Africa.

METHODS

Retrospective descriptive study. Records of VLBWI were reviewed for maternal HIV status, infant characteristics, diagnosis and outcome to hospital discharge. Anthropometry, morbidity and mortality were compared according to HIV-exposure.

RESULTS

Of 302 VLBWI,103 (34.1%)were HIV-exposed. Among the 103mothers, 38 (36.9%)were on combined anti-retroviral therapy (cART), 41 (39.8%) were on zidovudine (AZT) and 24 (23%) were not on either. More HIV-exposed VLBWI weighed v1000 g (41.2 vs 23.1%, Pv0.01). There were no differences in incidence or number of episodes of sepsis between HIV-exposed and -unexposed. More HIV-exposed VLBWI had severe intraventricular haemorrhage (IVH) (57.1 vs 11.4%, Pv0.01). The overall mortality rate was 27%, with HIV-exposed VLBWI having a mortality rate of 38.6% compared with 21% of the HIV-unexposed (Pv0.01). On multivariate analysis, the predictor of mortality was birthweight (Pv0.01).

CONCLUSION

HIV-exposed VLBWI are more likely to have extremely low birthweights. Morbidity in VLBWI is not affected by HIV-exposure, except for severe IVH. Birthweight is a predictor of mortality in VLBWI, irrespective of maternal HIV status.

Probiotics Reduce Necrotizing Enterocolitis Severity in HIV-exposed Premature Infants

OBJECTIVE

To assess the effect of probiotics on the incidence of necrotizing enterocolitis (NEC) in premature infants born to human immunodeficiency virus (HIV)-positive and HIV-negative women.

PATIENTS AND METHODS

HIV-exposed and HIV-unexposed premature infants were randomized to either the probiotic or the placebo group. The probiotic consisted of 1 × 10(9) colony-forming units, Lactobacillus rhamnosus GG and Bifidobacterium infantis per day.

RESULTS

In total, 74 HIV-exposed and 110 HIV-unexposed infants were enrolled and randomized. The incidence of death [4 (5.4%) vs. 7 (6%); p = 0.79] and NEC [4 (5%) vs. 5 (5%); p = 0.76] did not differ significantly between the HIV-exposed and HIV-unexposed groups. A significant difference was found for total NEC incidence between the study and control groups [3 (3%) vs. 6 (6%); p = 0.029]. The incidence of NEC in the HIV-exposed group differed significantly [Bells I 2 (5%) vs. Bells III 2 (5%); p = 0.045).

CONCLUSION

Probiotic supplementation reduced the incidence of NEC in the premature very low birth weight infants; however, results failed to show a lower incidence of NEC in HIV-exposed premature infants. A reduction in the severity of disease was found in the HIV-exposed study group.

Breastfeeding and the 2015 South African guidelines for prevention of mother-to-child transmission of HIV

No abstract available

Risk factors for necrotising enterocolitis in an HIV-endemic region

BACKGROUND

Several risk factors have been implicated in the development of necrotising enterocolitis (NEC). However, little has been reported on the risk factors for NEC in infants born in a setting where exposure to maternal human immunodeficiency virus (HIV) is prevalent.

OBJECTIVES

To determine maternal and infant characteristics associated with NEC in a setting with a high prevalence of HIV infection and to compare clinical presentation and mortality of NEC in HIV-exposed and unexposed infants.

METHODS

This was a retrospective, case-control study. Infants with a confirmed diagnosis of NEC, admitted between January 2005 and December 2008 were identified as cases. Two controls for each case were selected by matching them for birthweight, gestational age and date of birth. Hospital records were reviewed for maternal and infant characteristics.

RESULTS

One hundred and ten infants with confirmed NEC were identified and 220 were selected as controls. Median birthweight and gestational age were similar between cases and controls, (1370 and 1380 g, P = 0·96, and 31 weeks each, P = 0·62, respectively). Lack of use of antenatal corticosteroids (ANS) (OR 2·77, 95% CI 1·42-5·38, P = 0·003), presence of chorio-amnionitis (OR 7·28, 95% CI 2·16-24·51, P = 0·001) and not mechanically ventilated at birth (OR 3·54, 95% CI 1·29-9·69, P = 0·01) were independently associated with NEC. Maternal HIV status was not associated with NEC. Clinical presentation and mortality from NEC were similar between HIV-exposed and unexposed infants.

CONCLUSIONS

Infants who develop NEC were less likely to have received mechanical ventilation at birth, suggesting that they were less critically ill when born. Use of ANS should be encouraged as it is protective against NEC. Infants born to HIV-infected mothers were not at increased risk of NEC.

Necrotizing enterocolitis in HIV-exposed and nonexposed infants: clinical presentation and histopathological features

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in neonates and is associated with significant morbidity and mortality. An association between HIV-positive maternal status and increased risk of NEC in preterm infants has been described, and antiretroviral therapy has been proposed as an independent risk factor. Our aim was to compare the clinical presentation and histopathological features of necrotizing enterocolitis in HIV-exposed and unexposed infants. A retrospective study of archival material from the National Health Laboratory Services Histopathology Laboratory in Tygerberg Hospital/Stellenbosch University from 1992 to 2008 was conducted. All surgical specimens from infants who presented to pediatric surgery for a laparotomy and bowel resection for NEC and in whom the HIV status was known were included in the study. In the 37 cases that fulfilled these criteria, male gender was overrepresented in the study population (67%). Nonsteroidal anti-inflammatory drugs appeared to play a significant role in the development of surgical NEC in infants who were not exposed to HIV, but HIV-exposed infants had a significantly poorer survival rate. There was no significant difference in the histopathology between HIV-exposed and nonexposed infants, and Cytomegalovirus infection was not identified in any of the cases studied.

Surgical implications of human immunodeficiency virus infections

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

HIV exposure does not worsen outcome in stage III necrotizing enterocolitis with current treatment protocols

BACKGROUND/PURPOSE

The heavy burden of maternal HIV infection in developing countries such as South Africa has resulted in a high prevalence of premature birth and necrotizing enterocolitis (NEC). Uninfected infants born to HIV-infected mothers also demonstrate immune deficiencies. It is, therefore, essential to have a better understanding of how to mitigate HIV as an independent risk factor for surgically treated NEC and to evaluate the relevant contributing factors in the presence of an aggressive strategy of pasteurized breast milk feeding and antiretroviral prophylaxis.

METHODS

Infants with stage IIIb NEC presenting over a 4-year period were retrospectively reviewed. HIV-exposed infants were compared with non-HIV-exposed infants. Contributing factors were evaluated and studied by systematic statistical methods to evaluate risk.

RESULTS

Twenty percent (17/87) infants were HIV-exposed, and 80% (70/87), unexposed, whereas a further 10 (total, n = 97) had unknown HIV exposure status. Demographics and other perinatal risk factors between the 2 groups were not significantly different other than that HIV-exposed infants received pasteurized breast milk and nonexposed infants received unpasteurized breast milk. There were no statistically significant differences between the groups with respect to disease presentation or severity, surgical findings or type of surgery, postoperative complications, survival, or timing of death. Trends toward higher antenatal steroid exposure and increased postoperative sepsis in the HIV-exposed group (P = .03) were noted but were not related. All HIV-exposed infants received antiretrovirals; there were no significant differences on subanalysis between different antiretroviral regimens.

CONCLUSIONS

HIV-exposed infants do not have a more severe disease course nor more adverse outcomes in stage IIIb NEC than unexposed infants. Significant factors were antenatal steroids and post-NEC infective episodes.

Necrotizing enterocolitis: early conventional and fluorescein laparoscopic assessment

AIM

The clinical and radiological diagnosis of necrotizing enterocolitis (NEC) can be difficult. When radiological evidence is present, severity and complications, such as perforation and full-thickness necrosis, often may not be obvious. This study aims to establish early signs of full-thickness necrosis or perforation by using standard and fluorescein laparoscopy before clinical deterioration of patients occurs.

PATIENTS AND METHODS

Thirteen patients with preoperative presumed clinical and/or radiological diagnosis of NEC underwent laparoscopy. A 4.7-mm umbilical or left upper quadrant camera port was inserted by using the open method. The abdominal cavity was inspected for bowel ischemia, fibrin, adhesion formation, and presence of free intestinal contents. If necessary, one or two 3-mm working ports were inserted for manipulation of bowel.

RESULTS

Median age of 13 patients was 17 (3-38) days. Their median weight was 1160 (910-2415) g. The first 5 infants had standard laparoscopy only, with the next 8 having fluorescein-aided assessment added to the laparoscopy. Standard laparoscopy identified perforation in 5 patients and gangrenous bowel in 2. One patient was found to have chyle ascites, and 1 patient had no abnormal findings on laparoscopy. Fluorescein identified gangrenous bowel in 3 additional patients. Laparotomy and necessary surgical intervention were performed in all 10 patients with positive laparoscopy findings. Eleven patients survived and were doing well at a median of 9 (range, 6-39) months of follow-up.

CONCLUSION

Laparoscopy helps to improve assessment of patients with a diagnosis of NEC. It allows for early identification of perforation and necrosis. Where ischemia is suspected, fluorescein laparoscopy may have an added benefit in identifying necrotic segments.