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Mani S, Garg PM, Pammi M. Do hematological biomarkers predict surgical necrotizing enterocolitis? Pediatr Res 2024; 95:1680-1682. [PMID: 38297156 DOI: 10.1038/s41390-024-03066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/02/2024]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency in preterm infants and the clinical presentation of NEC may vary with gestational age. We lack reliable biomarkers for early diagnosis of NEC limiting timely intervention. Hematological changes in NEC are actively researched for their potential role as biomarkers. The pattern and severity of hematological abnormalities have been correlated with rapid progression, the need for surgery, increased risk of mortality, and morbidity. In this issue of Pediatric Research, Chong et al. report GA-specific hematological biomarkers in preterm infants with NEC that could predict the need for surgery. Thrombocytopenia at NEC onset was an independent predictor of surgical intervention in extremely preterm infants. Persistent thrombocytopenia and lymphopenia at 72 h and elevated C-reactive protein at 48 h after NEC onset, predicted surgery in infants of 28 to <32 weeks GA. Persistent thrombocytopenia at 24 h after the onset of NEC was predictive of mortality in infants who underwent surgery. Well-designed, prospective, multi-center studies are needed to confirm the role of hematological biomarkers in early diagnosis and prognostication in NEC.
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Affiliation(s)
- Srinivasan Mani
- Department of Pediatrics/Neonatology, The University of Toledo, ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH, USA
| | - Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Brenner Children's at Atrium Health Wake Forest Baptist and Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Mohan Pammi
- Dept. of Pediatrics, Division of Neonatology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA.
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Chong Q, Wang Z, Guo T, Zhang L, Lu L, Cai C, Gong X, Lv Z, Sheng Q. Gestational age-specific hematological features in preterm infants with necrotizing enterocolitis. Pediatr Res 2024; 95:1826-1836. [PMID: 38177247 DOI: 10.1038/s41390-023-02999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND This study aimed to investigate gestational age-specific hematological features in preterm infants with necrotizing enterocolitis (NEC) and identify predictive hematological biomarkers for surgical NEC. METHODS We conducted a retrospective study comparing gestational age (GA)-specific clinical data between medical NEC (m-NEC) and surgical NEC (s-NEC) subgroups, stratified by GA as <28 weeks, 28 ≤ GA < 32 weeks, and 32 ≤ GA < 37 weeks. Multivariate logistic analysis and receiver operating characteristic curve were used to identify the independent predictors of s-NEC. RESULTS In comparison to m-NEC at NEC onset, s-NEC infants exhibited the following findings: In GA < 28 weeks, s-NEC infants had lower platelet counts. In 28 ≤ GA < 32 weeks, lower absolute lymphocyte counts, and significant percent drop in platelets, lymphocytes, and monocytes were observed. In 32 ≤ GA < 37 weeks, lower absolute lymphocyte counts and significant percent drop in lymphocytes were found. Independent predictors were able to distinguish s-NEC from m-NEC. The area under the curve (AUC) for platelet counts in GA < 28 weeks was 0.880, while C-reactive protein in 28 ≤ GA < 32 weeks had an AUC of 0.889. The AUC for lymphocyte counts in 32 ≤ GA < 37 weeks was 0.892. CONCLUSION This study identified hematological abnormalities in the development of NEC based on gestational age. Independent predictors may help clinicians distinguish surgical NEC from medical NEC. IMPACT Necrotizing enterocolitis (NEC) patients with different gestational ages (GA) exhibit different hematological features and independent predictors of surgical NEC differ among different GAs. Our research made the current studies about peripheral hematological features with NEC more complete by analyzing peripheral data collected within 24 h of birth, at day 5-7, day 3-4, day 1-2 before NEC onset, at the time of NEC onset, day 1, day 2, day 3, day 4-5, day 6-7 after NEC onset. Our study is helpful to clinicians in developing a more detailed diagnostic strategy based on GA for the early identification of surgical NEC.
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Affiliation(s)
- Qingqi Chong
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Zhiru Wang
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Ting Guo
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Liaoran Zhang
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Li Lu
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Cheng Cai
- Department of Neonatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China
| | - Zhibao Lv
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China.
| | - Qingfeng Sheng
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No. 355, Luding Rd, 200062, Shanghai, PR China.
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Garg PM, Lett K, Ansari MAY, Cunningham H, Ware J, Pittman I, Riddick R, Sawaya D, Berch B, Morris M, Varshney N, Shenberger JS, Taylor C, Reddy K, Hillegass W. Outcomes by disease onset, sex, and intervention in neonates with SIP and surgical NEC. Pediatr Res 2024; 95:1009-1021. [PMID: 37488302 DOI: 10.1038/s41390-023-02749-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Outcomes of infants following surgical necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) categorized by the age of onset, interventions, and sex are not well defined. METHODS Retrospective comparison of infants categorized by age of onset (NEC at <10, 10-20, and >20 days) and SIP at <7 versus ≥7 days), sex, and intervention [Penrose Drain (PD) vs. laparotomy]. RESULTS A total of 114 infants had NEC and 37 had SIP. On multinomial logistic regression, infants with NEC/SIP onset >20 days had significantly lower odds of small bowel involvement (aOR = 0.07, 95% CI: 0.01-0.33, p = 0.001), higher necrosis (aOR = 3.59, 95% CI: 1.34-9.65, p = 0.012) and higher CRP (p = 0.004) than onset <10 days. Initial laparotomy was associated with more bowel loss (24.1 cm [12.3; 40.6] vs.12.1 [8.00; 23.2]; p = 0.001), small and large intestine involvement (47.1% vs 17.2%; p = 0.01), and ileocecal valve resection (42% vs. 19.4%; p = 0.036) than initial PD therapy. Females underwent fewer small bowel resections (52.3% vs 73.6%; p = 0.025) but had higher surgical morbidity (53.7% vs. 24.7%.; p = 0.001) than males. CONCLUSION Clinical, radiological, and histopathological presentation and outcomes in preterm infants with surgical NEC/SIP are associated with age of disease onset, sex, and initial intervention. IMPACT Neonates with surgical NEC onset >20 days had more severe necrosis, inflammation, kidney injury, and bowel loss than those with <10 days. Initial laparotomy was associated with later age onset, more bowel loss, and ileocecal valve resection compared to initial PD treatment, but not with differences in mortality or length of stay. Female sex was associated with lower maturity, more placental malperfusion, less often small bowel involvement, lower pre-NEC hematocrit as well as higher surgical morbidity than males. Whether the management of surgical NEC and SIP should differ by the age of onset requires further investigation.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Wake Forest University, Winston-Salem, NC, USA.
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA.
| | - Katheryn Lett
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Md Abu Yusuf Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MI, USA
| | - Helen Cunningham
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jennifer Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Isabella Pittman
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Robin Riddick
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - David Sawaya
- Department of Pediatric Surgery, University of Mississippi Medical Center, Jackson, MI, USA
| | - Berry Berch
- Department of Pediatric Surgery, University of Mississippi Medical Center, Jackson, MI, USA
| | - Michael Morris
- Department of Pathology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Neha Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jeffrey S Shenberger
- Department of Pediatrics/Neonatology, Wake Forest University, Winston-Salem, NC, USA
| | - Charlotte Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Kartik Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, MI, USA
| | - William Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MI, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MI, USA
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Garg PP, Riddick R, Ansari MAY, Pittman I, Ladd MR, Porcelli P, Garg PM. Risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis and associated outcomes. J Neonatal Perinatal Med 2024; 17:77-89. [PMID: 38217616 PMCID: PMC10939752 DOI: 10.3233/npm-230076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
BACKGROUND We aim to determine clinical risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). METHODS A retrospective cohort study of preterm infants with surgical NEC or SIP to compare clinical factors between those with and without postoperative complications. RESULTS 78/109 (71.5%) infants had any complication following surgical NEC. Adhesions (20/35, 57.1%) and wound infection (6/35, 17.1%) were the most common single surgical complications. Patients with a single surgical complication (35/66, 53%) were significantly less likely to be exposed to antenatal steroids, more frequently had a jejunostomy, needed a central line longer, and had a longer length of stay than those without any surgical complication. Infants with > 1 surgical complication (43/71, 60.5%) included mainly females, and had AKI more frequently at NEC onset, lower weight z-scores and lower weight for length z- scores at 36 weeks PMA than those without any complications.On multinomial logistic regression, antenatal steroids exposure (OR 0.23 [CI 0.06, 0.84]; p = 0.027) was independently associated with lower risk and jejunostomy 4.81 (1.29, 17.9) was independently associated with higher risk of developing a single complication. AKI following disease onset (OR 5.33 (1.38, 20.6), P = 0.015) was independently associated with > 1 complication in surgical NEC/SIP infants. CONCLUSION Infants with postoperative complications following surgical NEC were more likely to be female, have additional morbidities, and demonstrate growth failure at 36 weeks PMA than those without surgical complications. There was no difference in mortality between those with and without surgical complications.
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Affiliation(s)
- P P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - R Riddick
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - M A Y Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - I Pittman
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - M R Ladd
- Department of General Surgery/Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - P Porcelli
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - P M Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
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Puri S, Sen IM, Bhardwaj N, Yaddanapudi S, Mathew PJ, Bandyopadhyay A, Samujh R, Dogra S, Kumar P. Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study. Paediatr Anaesth 2023; 33:1075-1082. [PMID: 37483171 DOI: 10.1111/pan.14731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
AIMS Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality. METHODS This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed. RESULTS Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced. CONCLUSION Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.
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Affiliation(s)
- Sunaakshi Puri
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indu Mohini Sen
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neerja Bhardwaj
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandhya Yaddanapudi
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Preethy J Mathew
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjishnujit Bandyopadhyay
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Department of Paediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivani Dogra
- Department of Paediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Department of Neonatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Garg PM, Pittman IA, Ansari MAY, Yen CW, Riddick R, Jetton JG, South AM, Hillegass WB. Gestational age-specific clinical correlates of acute kidney injury in preterm infants with necrotizing enterocolitis. Pediatr Res 2023; 94:2016-2025. [PMID: 37454184 PMCID: PMC10937190 DOI: 10.1038/s41390-023-02736-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/02/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND To study the gestational age-specific risk factors and outcomes of severe acute kidney injury (AKI) in neonates with necrotizing enterocolitis (NEC). METHODS Retrospective cohort study comparing gestational age (GA)-specific clinical data between infants without severe AKI (stage 0/1 AKI) and those with severe AKI (stages 2 and 3 AKI) stratified by GA ≤27 and >27 weeks. RESULTS Infants with GA ≤27 weeks had double the rate of severe AKI (46.3% vs. 20%). In infants with GA >27 weeks, male sex, outborn, and nephrotoxic medication exposure were associated with severe AKI. On multivariable logistic regression, in infants with GA ≤27 weeks, surgical NEC (OR 35.08 (CI 5.05, 243.73), p < 0.001) and ostomy (OR 6.2(CI 1.29, 29.73), p = 0.027) were associated with significantly higher odds of severe AKI. Surgical NEC infants with GA >27 weeks and severe AKI were significantly more likely to be outborn, have later NEC onset, need dopamine, and have longer hospitalization (158 days [110; 220] vs.75.5 days [38.8; 105]; p = 0.007 than those with non-severe AKI. CONCLUSION In neonates with NEC, surgical intervention was associated with moderate-to-severe AKI in infants with GA ≤27 weeks and with longer hospitalization in infants with GA >27 weeks. IMPACT In both cohorts need for surgery, stoma, cholestasis, and mechanical ventilation were associated with severe AKI; however, the infants with GA <27 weeks had twice the risk of severe AKI than GA >27 weeks group. The longer exposure to nephrotoxic medication and referral need were significant risk factors for AKI in GA >27 weeks group. GA-specific kidney protective and monitoring strategies to prevent AKI and its consequences are needed to improve the clinical outcomes in neonates with NEC. Understanding the risk factors and short- and long-term outcomes unique to different GA groups will help inform those strategies.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist Hospital, Wake Forest University School of Medicine, Winston Salem, NC, USA.
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Isabella A Pittman
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Chin Wen Yen
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Robbin Riddick
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jennifer G Jetton
- Section of Pediatric Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew M South
- Department of Pediatrics-Section of Nephrology, Brenner Children's, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - William B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Garg PM, Lett K, Ansari MAY, Pittman I, Riddick R, Varshney N, Morris M, Sawaya D, Taylor C, Reddy K, Porcelli P, Hillegass W. Postoperative Outcomes, and Growth and Brain Injury Outcomes in Spontaneous Intestinal Perforation vs Surgical Necrotizing Enterocolitis in Preterm Infants. Indian Pediatr 2023; 60:922-926. [PMID: 37700582 PMCID: PMC10842114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
OBJECTIVE To compare the clinical outcomes in preterm infants following surgical necrotizing enterocolitis (sNEC) and spontaneous intestinal perforation (SIP). METHODS Retro-spective comparison of clinical information in preterm infants with sNEC and SIP admitted between January, 2013 and December 31, 2018. The clinical outcomes were compared in two groups, including postoperative and brain injury detected on brain magnetic resonance imaging (MRI) after clinical and histopathological confirmation of the SIP and the NEC diagnosis. RESULTS 114 infants had sNEC, and 37 had SIP. Infants with SIP had lower median gestational age [25.1 weeks (23.5, 27.1) vs 26.6 (24.4, 31.0), P=0.03], an earlier mean (SD) age of disease onset [10.1 (11.3) days vs 19.6 (17.9); P<0.001] and lower maternal chorioamnionitis on placental pathology [4 (23.5%) vs 22 (68.8%); P=0.007), received more often Penrose drain therapy (54% vs 33%; P=0.03), had less median (IQR) bowel length loss [3.3 cm (1.72, 4.38) vs 21.4 (9.55, 35.3); P=<0.001] and had more often intact ileocecal valve (91.4% vs 65.7%; P=0.006] compared to those with sNEC. In addition, those with sNEC had lower median (IQR) weight z scores at the time of discharge [-1.88 (-2.80, -1.09) vs -1.14 (-2.22, -0.44); P=0.036] than SIP. There were no significant differences in postoperative ileus, duration of parenteral nutrition, surgical morbidity, length of stay, mortality, white matter, and grey matter injury on brain MRI at term equivalent age in preterm infants with SIP and sNEC. CONCLUSION In our cohort, preterm infants with SIP and sNEC did not show significant differences in postoperative morbidity and brain MRI abnormalities at term equivalent age. sNEC had lower discharge weight z scores. Larger prospective studies are needed for confirmation of these findings.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, USA and Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Katheryn Lett
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Md Abu Yusuf Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Isabella Pittman
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Robin Riddick
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Neha Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael Morris
- Department of Pediatric Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - David Sawaya
- Department of Pediatric Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Charlotte Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kartik Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Peter Porcelli
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - William Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA and Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Garg PM, Pittman I, Yi J, Weis VG, Rodriguez RJ, Ladd MR, Rauh JL, McDonald AG, Welch C, Premkumar MH, Garg PP, Maheshwari A. Clinical Correlates of Cholestasis in Preterm Infants with Surgical Necrotizing Enterocolitis. NEWBORN (CLARKSVILLE, MD.) 2023; 2:191-197. [PMID: 37974929 PMCID: PMC10653206 DOI: 10.5005/jp-journals-11002-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Background We sought to investigate the clinical determinants and outcomes of cholestasis in preterm infants with surgical necrotizing enterocolitis (sNEC). Methods Retrospective comparison of clinical information in preterm infants who developed cholestasis vs those who did not. Results Sixty-two (62/91, 68.1%) infants with NEC developed cholestasis at any time following the onset of illness. Cholestasis was seen more frequently in those who had received ionotropic support at 24 hours following sNEC diagnosis (87.1% vs 58.6%; p = 0.002), had higher mean C-reactive protein levels 2 weeks after NEC diagnosis (p = 0.009), had blood culture-positive sepsis [25 (40.3%) vs 4 (13.8%); p = 0.011], received parenteral nutrition (PN) for longer durations (108.4 ± 56.63 days vs 97.56 ± 56.05 days; p = 0.007), had higher weight-for-length z scores at 36 weeks' postmenstrual age [-1.0 (-1.73, -0.12) vs -1.32 (-1.76, -0.76); p = 0.025], had a longer length of hospital stay (153.7 ± 77.57 days vs 112.51 ± 85.22 days; p = 0.024), had intestinal failure more often (61% vs 25.0%, p = 0.003), had more surgical complications (50% vs 27.6%; p = 0.044), and had >1 complication (21% vs 3.4%; p = 0.031). Using linear regression, the number of days after surgery when feeds could be started [OR 15.4; confidence interval (CI) 3.71, 27.13; p = 0.009] and the postoperative ileus duration (OR 11.9, CI 1.1, 22.8; p = 0.03) were independently associated with direct bilirubin between 2 and 5 mg/dL (mild-moderate cholestasis) at 2 months of age. The duration of PN was independently associated with direct bilirubin >5 mg/dL (severe cholestasis) at 2 months of age in these patients. Conclusion Cholestasis was seen in 68% of infants following surgical NEC. The most likely contributive factors are intestinal failure and subsequent PN dependence for longer periods. Our data suggest that identification and prevention of risk factors such as sepsis and surgical complications and early feeds following NEC surgery may improve outcomes.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Global Newborn Society, Clarksville, Maryland, United States of America
| | - Isabella Pittman
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Joe Yi
- Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, NC, United States of America
| | - Victoria G Weis
- Department of Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Ricardo Jorge Rodriguez
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Mitchell R Ladd
- Department of Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Jessica L Rauh
- Department of Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Anna Greene McDonald
- Department of Pathology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Cherrie Welch
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | | | - Padma P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Akhil Maheshwari
- Global Newborn Society, Clarksville, Maryland, United States of America
- Louisiana State University Health Sciences Center – Shreveport, LA, United States of America
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Scheese DJ, Sodhi CP, Hackam DJ. New insights into the pathogenesis of necrotizing enterocolitis and the dawn of potential therapeutics. Semin Pediatr Surg 2023; 32:151309. [PMID: 37290338 PMCID: PMC10330774 DOI: 10.1016/j.sempedsurg.2023.151309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disorder in premature infants that causes significant morbidity and mortality. Research efforts into the pathogenesis of NEC have discovered a pivotal role for the gram-negative bacterial receptor, Toll-like receptor 4 (TLR4), in its development. TLR4 is activated by dysbiotic microbes within the intestinal lumen, which leads to an exaggerated inflammatory response within the developing intestine, resulting in mucosal injury. More recently, studies have identified that the impaired intestinal motility that occurs early in NEC has a causative role in disease development, as strategies to enhance intestinal motility can reverse NEC in preclinical models. There has also been broad appreciation that NEC also contributes to significant neuroinflammation, which we have linked to the effects of gut-derived pro-inflammatory molecules and immune cells which activate microglia in the developing brain, resulting in white matter injury. These findings suggest that the management of the intestinal inflammation may secondarily be neuroprotective. Importantly, despite the significant burden of NEC on premature infants, these and other studies have provided a strong rationale for the development of small molecules with the capability of reducing NEC severity in pre-clinical models, thus guiding the development of specific anti-NEC therapies. This review summarizes the roles of TLR4 signaling in the premature gut in the pathogenesis of NEC, and provides insights into optimal clinical management strategies based upon findings from laboratory studies.
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Affiliation(s)
- Daniel J Scheese
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - David J Hackam
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA.
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10
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Li W, Zhang C, Li W, Qin F, Gao X, Xu F. Nomogram for predicting fulminant necrotizing enterocolitis. Pediatr Surg Int 2023; 39:154. [PMID: 36939896 PMCID: PMC10027821 DOI: 10.1007/s00383-023-05435-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Fulminant necrotizing enterocolitis (FNEC) is the most serious subtype of NEC and has a high mortality rate and a high incidence of sequelae. Onset prediction can help in the establishment of a customized treatment strategy. This study aimed to develop and evaluate a predictive nomogram for FNEC. METHODS We conducted a retrospective observation to study the clinical data of neonates diagnosed with NEC (Bell stage ≥ IIB). Neonates were divided into the FNEC and NEC groups. A multivariate logistic regression model was used to construct the nomogram model. The performance of the nomogram was assessed using area under the curve, calibration analysis, and decision curve analysis. RESULTS A total of 206 neonate cases were included, among which 40 (19.4%) fulfilled the definition of FNEC. The identified predictors were assisted ventilation after NEC onset; shock at NEC onset; feeding volumes before NEC onset; neutrophil counts on the day of NEC onset; and neutrophil, lymphocyte, and monocyte counts on day 1 after NEC onset. The nomogram exhibited good discrimination, with an area under the receiver operating characteristic curve of 0.884 (95% CI 0.825-0.943). The predictive model was well calibrated. Decision curve analysis confirmed the clinical usefulness of this nomogram. CONCLUSION A nomogram with a potentially effective application was developed to facilitate the individualized prediction of FNEC, with the hope of providing further direction for the early diagnosis of FNEC and timing of intervention.
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Affiliation(s)
- Weibo Li
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Branch Center of the Third Affiliated Hospital of Advanced Medical Research Center of Zhengzhou University, Zhengzhou, Henan, China
| | - Chen Zhang
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Branch Center of the Third Affiliated Hospital of Advanced Medical Research Center of Zhengzhou University, Zhengzhou, Henan, China
| | - Wenli Li
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Branch Center of the Third Affiliated Hospital of Advanced Medical Research Center of Zhengzhou University, Zhengzhou, Henan, China
| | - Fanyue Qin
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Branch Center of the Third Affiliated Hospital of Advanced Medical Research Center of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiang Gao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Falin Xu
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
- Branch Center of the Third Affiliated Hospital of Advanced Medical Research Center of Zhengzhou University, Zhengzhou, Henan, China.
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11
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Klinke M, Chaaban H, Boettcher M. The role of neutrophil extracellular traps in necrotizing enterocolitis. Front Pediatr 2023; 11:1121193. [PMID: 37009300 PMCID: PMC10050739 DOI: 10.3389/fped.2023.1121193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/27/2023] [Indexed: 04/04/2023] Open
Abstract
Necrotizing enterocolitis (NEC) continues to be one of the most common causes of mortality and morbidity in preterm infants. Although not fully elucidated, studies suggest that prematurity, formula feeding, imbalanced vascular supply, and altered bacterial colonization play major roles in the pathogenesis of NEC. NEC is characterized by increased cytokine release and leukocyte infiltration. Recent data from preterm infants and animal models of NEC suggest that neutrophil extracellular traps (NETs) are released in intestinal tissue. The contribution of NETs in the pathogenesis and/or prevention/treatment of this disease continues to be controversial. Here, we review the available data on NETs release in NEC in human patients and in different NEC models, highlighting their potential contribution to pathology and resolution of inflammation. Here, we review the available data on NETs release in NEC in human patients and the different NEC models, highlighting their potential contribution to pathology or resolution of inflammation.
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Affiliation(s)
- Michaela Klinke
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hala Chaaban
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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12
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Abstract
Platelet plug formation is critically involved in murine ductus arteriosus closure and thrombocytopenia in preterm infants seems to negatively affect spontaneous and pharmacologically induced ductal closure. Furthermore, platelet dysfunction may contribute to ductal patency, especially in extremely immature infants. Neonatal platelets likely have multifaceted roles during ductal closure, such as secretion of several signaling molecules and facilitation of specific cell-cell interactions. The only available randomized-controlled trial on platelet transfusions in preterm infants with patent ductus arteriosus demonstrated that a liberal transfusion regimen did not promote ductal closure, but was associated with an increased rate of intraventricular hemorrhage. Herein, we discuss the available mechanistic evidence on the role of platelets in ductus arteriosus closure and their potential clinical implications in preterm infants. We further briefly outline future research directions aimed at a better understanding of platelet-endothelial interactions in neonatal health and disease.
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Affiliation(s)
- Hannes Sallmon
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Division of Pediatric Cardiology, Graz Medical University, Graz, Austria.
| | - Cassidy A Delaney
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA
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13
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Zhang X, Zhang Y, He Y, Zhu X, Ai Q, Shi Y. β-glucan protects against necrotizing enterocolitis in mice by inhibiting intestinal inflammation, improving the gut barrier, and modulating gut microbiota. J Transl Med 2023; 21:14. [PMID: 36627673 PMCID: PMC9830848 DOI: 10.1186/s12967-022-03866-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease with high morbidity and mortality, affecting preterm infants especially those with very low and extremely low birth weight. β-glucan has manifested multiple biological effects including anti-inflammatory, regulation of gut microbiota, and immunomodulatory activities. This study aimed to investigate the effects of β-glucan on NEC. METHODS Neonatal C57BL/6 mice were randomly divided into three groups: Control group, NEC group and β-glucan group. Newborn 3-day-old mice were gavaged with either 1 mg/ml β-glucan or phosphate buffer saline at 0.03 ml/g for 7 consecutive days before NEC induction and a NEC model was established with hypoxia combined with cold exposure and formula feeding. All the pups were killed after 72-h modeling. Hematoxylin-eosin staining was performed to assess the pathological injury to the intestines. The mRNA expression levels of inflammatory factors in intestinal tissues were determined using quantitative real-time PCR. The protein levels of TLR4, NF-κB and tight junction proteins in intestinal tissues were evaluated using western blotting and immunohistochemistry. 16S rRNA sequencing was performed to determine the structure of the gut microbiota. RESULTS β-glucan administration ameliorated intestinal injury of NEC mice; reduced the intestinal expression of TLR4, NF-κB, IL-1β, IL-6, and TNF-α; increased the intestinal expression of IL-10; and improved the expression of ZO-1, Occludin and Claudin-1 within the intestinal barrier. Pre-treatment with β-glucan also increased the proportion of Actinobacteria, Clostridium butyricum, Lactobacillus johnsonii, Lactobacillus murinus, and Lachnospiraceae bacterium mt14 and reduced the proportion of Klebsiella oxytoca g Klebsiella in the NEC model. CONCLUSION β-glucan intervention prevents against NEC in neonatal mice, possibly by suppressing the TLR4-NF-κB signaling pathway, improving intestinal barrier function, and partially regulating intestinal microbiota.
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Affiliation(s)
- Xingdao Zhang
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuni Zhang
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yu He
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xingwang Zhu
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qing Ai
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuan Shi
- grid.488412.3Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China ,grid.488412.3Chongqing Key Laboratory of Pediatrics, Chongqing, China
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14
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Garg PM, Denton MX, Talluri R, Ansari MAY, Riddick R, Ostrander MM, McDonald AG, Premkumar MH, Hillegass WB, Garg PP. Clinical determinants of intestinal failure and death in preterm infants with surgical necrotizing enterocolitis. J Neonatal Perinatal Med 2023; 16:589-596. [PMID: 38007677 PMCID: PMC10841979 DOI: 10.3233/npm-230157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
OBJECTIVE We sought to investigate the clinical determinants of intestinal failure and death in preterm infants with surgical NEC. METHODS Retrospective comparison of clinical information between Group A = intestinal failure (Parenteral nutrition (PN) >90 days) and death and Group B = survivors and with PN dependence < 90 days in preterm infants with surgical NEC. RESULTS Group A (n = 99/143) had a lower mean gestational age (26.4 weeks [SD3.5] vs. 29.4 [SD 3.5]; p = 0.013), lower birth weight (873 gm [SD 427g] vs. 1425 gm [894g]; p = <0.001), later age of NEC onset (22 days [SD20] vs. 16 days [SD 17]; p = 0.128), received surgery later (276 hours [SD 544] vs. 117 hours [SD 267]; p = 0.032), had cholestasis, received dopamine (80.6% vs. 58.5%; p = 0.010) more frequently and had longer postoperative ileus time (19.8 days [SD 15.4] vs. 11.8 days [SD 6.5]; p = <0.001) and reached full feeds later (93 days [SD 45] vs. 44 [SD 22]; p = <0.001) than Group B.On multivariate logistic regression, higher birth weight was associated with lower risk (OR 0.35, 95% CI 0.15-0.82; p = 0.016) of TPN > 90 days or death. Longer length of bowel resected (OR 1.76, 95% CI 1.02-3.02; p = 0.039) and longer postoperative ileus (OR 2.87, 95% CI 1.26-6.53; p = 0.011) were also independently associated with TPN >90days or death adjusted for gestational age and antenatal steroid treatment. CONCLUSION In preterm infants with surgical NEC, clinical factors such as lower birth weight, longer bowel loss, and postoperative ileus days were significantly and independently associated with TPN >90 days or death.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M X Denton
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Talluri
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - M A Y Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Riddick
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M M Ostrander
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - A G McDonald
- Department of Pathology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - M H Premkumar
- Department of Pediatrics/Neonatology, Texas Children Hospital, Baylor College of Medicine, Houston, TX, USA
| | - W B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - P P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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15
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Garg PM, Denton MX, Talluri R, Ostrander MM, Middleton C, Sonani H, Varshney N, Hillegass WB. Clinical determinants and impact of hemorrhagic lesions on intestinal pathology in preterm infants with surgical necrotizing enterocolitis. J Neonatal Perinatal Med 2022; 16:119-128. [PMID: 36565070 DOI: 10.3233/npm-221116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We sought to determine the clinical and histopathological factors associated with intestinal hemorrhage and its correlation with clinical outcomes in neonates with surgical necrotizing enterocolitis (NEC). METHODS A retrospective study compared clinical and histopathology information in neonates following surgical NEC with severe hemorrhage and those with mild/moderate hemorrhagic lesions seen on resected intestine pathology. RESULTS The infants with severe hemorrhage (Grade 3-4, 81/148, 54.7%) had significantly lower exposure to antenatal steroids (52.5 % vs 76.9 % ; p = 0.004), had higher gestational age (28.5 weeks [7.14] vs. 26.58 [2.90]; p = 0.034), lost more bowel length (p = 0.045), had higher CRP levels at 2 weeks (p = 0.035), and had less intestinal failure ([30.3 % vs 52.5 %]; p = 0.014) than mild/moderate (Grade 0-2, 67/148, 45.2%) hemorrhage group. Those with severe hemorrhage had significantly higher mean inflammation score (2.67 [0.94] vs. 1.63 [0.92]; p = <0.001), higher necrosis scores (1.95 [1.28] vs. 1.49 [1.35]; p = 0.037), higher neovascularization (p = 0.01), higher fibroblasts (p = 0.023) and higher lymphocyte percentages up to 48 hours (p < 0.05) following NEC than mild/ moderate hemorrhage group.On multivariable regression, less exposure to antenatal steroids (OR 0.18 [95% CI 0.05-0.58]; p = 0.005), higher inflammation (OR 3.7 [95% CI 2.09-7.32]; p = 0.001), and lymphocyte count on the day of onset/24 hours following NEC (OR 1.06 [95% CI 1.02-1.11]; p = 0.005) were independently associated with a higher odd of severe intestinal hemorrhage. CONCLUSION The surgical NEC infants with intestinal hemorrhage were less likely to have antenatal steroid exposure but had higher inflammation grade and lymphocyte counts following NEC onset on multivariable regression modeling.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - M X Denton
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - R Talluri
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi
| | - M M Ostrander
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - C Middleton
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - H Sonani
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - N Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - W B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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16
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Garg PM, Paschal JL, Ware J, Hobart HL, O'Connor A, Ansari MAY. Gestational age-specific hematological patterns in preterm infants following necrotizing enterocolitis. J Matern Fetal Neonatal Med 2022; 35:10093-10102. [PMID: 36062737 PMCID: PMC9704046 DOI: 10.1080/14767058.2022.2115885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/28/2022] [Accepted: 07/12/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To investigate gestational age (GA) specific hematological and transfusion response patterns in preterm infants following necrotizing enterocolitis (NEC). DESIGN A retrospective study comparing hematological/transfusion information in three GA groups' infants: Group A ≤ 28 weeks. Group B 28-32 weeks, Group C > 32 weeks following necrotizing enterocolitis. RESULTS Group A infants responded with significantly higher WBC count, thrombocytopenia, higher absolute neutrophil, and higher absolute monocyte and lower absolute lymphocyte counts following NEC onset, received more blood transfusions before NEC onset (59.8 versus 30.0%; p = .007), and had higher odds of surgical NEC (OR 3.39 [95% CI 1.19-10.38]; p = .02) than group C. One unit increase in absolute lymphocyte count on the day, and 24 h following NEC was significantly associated with lower surgical NEC odds than groups C. CONCLUSION The infant's in-group A had significantly different hematological response patterns following NEC than infants with higher gestational age (groups B and C).
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jennifer Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Haley L Hobart
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Anna O'Connor
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Md Abu Yusuf Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, MI, USA
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17
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Qin F, Yuan M, Zhang C, Zhu C, Dong H, Xu F. Association of neutropenia at disease onset with severe surgical necrotizing enterocolitis and higher mortality: A retrospective study. Front Surg 2022; 9:971898. [PMID: 36303851 PMCID: PMC9592859 DOI: 10.3389/fsurg.2022.971898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Neutrophils are among the earliest immune cells recruited to the site of an intestinal injury, but their predictive role in the progression of necrotizing enterocolitis (NEC) has not been fully elucidated. This study aimed to evaluate if a reduction in neutrophils at the onset of NEC is associated with severe surgical NEC and/or NEC-associated deaths. Methods This is a retrospective cohort study in which neonates underwent surgery due to NEC during 2015-2020. The data on absolute neutrophil count (ANC), before and at the onset of NEC, were collected from the complete blood count results. The primary exposure was the difference in absolute neutrophil count (ΔANC) at NEC onset. The primary outcome was severe surgical NEC, defined as the residual small bowel length after intestinal resection of <30 cm. Results A total of 157 neonates were included in this study, of which 53 were diagnosed with severe surgical NEC. A decrease in ANC at the onset of NEC was associated with an increased probability of severe surgical NEC (crude odds ratio [OR] 1.248, 95% CI 1.107-1.407; P = 0.000). ΔANC (area under the curve [AUC] 0.729, 95% CI 0.653-0.797; P < 0.001] was a good predictor for severe surgical NEC. The addition of platelets to ΔANC at NEC onset (AUC 0.738, 95% CI 0.662-0.808; P < 0.001) resulted in a higher AUC and specificity for severe surgical NEC prediction than ΔANC alone. A reduction in the neutrophil count at NEC onset (ΔANC > 0) was associated with adverse outcomes (hazard ratio [HR] 3.48, 95% CI 1.64-7.36) and a lower survival probability (χ2 10.63; P < 0.001). Conclusion A reduction in the ANC at the onset of NEC was associated with severe surgical NEC and higher mortality. The addition of platelets to ΔANC at NEC onset resulted in a higher predictive value of severe surgical NEC. This study may provide a new insight into the bedside evaluation of NEC by analyzing data from the day of NEC onset.
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Affiliation(s)
- Fanyue Qin
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengjie Yuan
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chen Zhang
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chu Zhu
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huifang Dong
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Advanced Medical Research Center of Zhengzhou University, Zhengzhou, China
| | - Falin Xu
- Department of Neonatology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Advanced Medical Research Center of Zhengzhou University, Zhengzhou, China,Correspondence: Falin Xu
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18
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Bench to bedside - new insights into the pathogenesis of necrotizing enterocolitis. Nat Rev Gastroenterol Hepatol 2022; 19:468-479. [PMID: 35347256 DOI: 10.1038/s41575-022-00594-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Necrotizing enterocolitis (NEC) is the leading cause of death and disability from gastrointestinal disease in premature infants. Recent discoveries have shed light on a unifying theorem to explain the pathogenesis of NEC, suggesting that specific treatments might finally be forthcoming. A variety of experiments have highlighted how the interaction between bacterial signalling receptors on the premature intestine and an abnormal gut microbiota incites a pro-inflammatory response in the intestinal mucosa and its underlying endothelium that leads to NEC. Central amongst the bacterial signalling receptors implicated in NEC development is the lipopolysaccharide receptor Toll-like receptor 4 (TLR4), which is expressed at higher levels in the premature gut than in the full-term gut. The high prenatal intestinal expression of TLR4 reflects the role of TLR4 in the regulation of normal gut development, and supports additional studies indicating that NEC develops in response to signalling events that occur in utero. This Review provides new evidence explaining the pathogenesis of NEC, explores new findings indicating that NEC development has origins before birth, and discusses future questions and opportunities for discovery in this field.
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Gunasekaran A, Devette C, Levin S, Chaaban H. Biomarkers of Necrotizing Enterocolitis: The Search Continues. Clin Perinatol 2022; 49:181-194. [PMID: 35210000 DOI: 10.1016/j.clp.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) emergency in the neonatal intensive care unit. Despite advances in medical care, mortality and morbidity from NEC have not changed. This is likely due to the lack of a clear understanding of this multifactorial disease, and reliable biomarkers for accurate diagnosis of NEC. Currently, the diagnosis of NEC is made by a combination of nonspecific clinical signs, symptoms, and radiological findings. Though biomarkers have been studied extensively, none offer an acceptable sensitivity or specificity to be used. This review will focus on the available literature on biomarkers for preterm NEC, acknowledging the limitations in studies including the variability of inclusion criteria, and most importantly, the lack of gold standard case definition for NEC.
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Affiliation(s)
- Aarthi Gunasekaran
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA
| | - Christa Devette
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Samuel Levin
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Hala Chaaban
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
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20
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Chen J, Zhong W, Hou L, Lin T, Lyv J, Tian Y, Ma Z, He Q, Zhong W. Predictive factors for rapid progression in preterm neonates with necrotizing enterocolitis. Front Pediatr 2022; 10:970998. [PMID: 36699309 PMCID: PMC9869057 DOI: 10.3389/fped.2022.970998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency with significant mortality and morbidity rates. A subset of patients progressed rapidly and underwent surgical intervention within a short period. This study aimed to establish a model to predict the rapid progression of NEC in preterm neonates. METHODS A retrospective study was conducted to review neonates with NEC between December 2015 and April 2019 at the Guangzhou Women and Children's Medical Center. Rapidly progressive NEC was defined as the need for surgical intervention or death within 48 h of NEC onset. Patients were divided into two groups: rapidly progressive NEC (RP-NEC) and non-rapidly progressive NEC (nRP-NEC). Data on demographics, perinatal characteristics, examination variables, and radiographic findings at onset were collected. RESULTS A total of 216 preterm neonates with NEC were included in the study, of which 64 had RP-NEC and 152 had nRP-NEC. The mortality rates of patients with RP-NEC and nRP-NEC were 32.8% and 3.28%, respectively. Male sex (p-value, adjusted odds ratio [95% confidence interval]: 0.002, 3.43 [1.57, 7.53]), portal venous gas (0.000, 8.82 [3.73, 20.89]), neutrophils <2.0 × 109/L (0.005, 4.44 [1.59, 12.43]), pH <7.3 (7.2 ≤ pH < 7.3) (0.041, 2.95 [1.05, 8.31]), and pH <7.2 (0.000, 11.95 [2.97, 48.12]) at NEC onset were identified as independent risk factors for RP-NEC. An established model that included the four risk factors presented an area under the curve of 0.801 with 83% specificity and 66% sensitivity. CONCLUSION Among preterm neonates with NEC, a significantly higher mortality rate was observed in those with rapid progression. It is recommended that close surveillance be performed in these patients, and we are confident that our established model can efficiently predict this rapid progression course.
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Affiliation(s)
- Jiale Chen
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Weitao Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Longlong Hou
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Tulian Lin
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Junjian Lyv
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yan Tian
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zuyi Ma
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qiuming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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