Risk factors and epidemiology of spontaneous intestinal perforation among infants born at 22-24 weeks' gestational age

The Association Between Perinatal Pharmacologic Treatments and Spontaneous Intestinal Perforation in Extremely Preterm Infants: A Propensity Score Matching Study

Background: The impact of perinatal pharmacologic agents on spontaneous intestinal perforation (SIP) in extremely low-birthweight (ELBW, <1000 g) preterm infants remains inconclusive based on findings from retrospective cohort or case-control studies. This study aims to address this uncertainty by using propensity score matching (PSM) to reduce bias. Methods: We retrospectively reviewed ELBW infants in our unit between 2014 and 2023 to identify SIP cases. Confirmed through medical notes, surgical consultation, and author review, each SIP case was matched at a 1:3 ratio using propensity scores on factors including the gestational age (GA), birthweight, gender, and birth year. Pharmacologic agents commonly given antenatally and postnatally were analyzed. Only medications that were started 24 h before the onset of SIP or the corresponding age (PSM-controls) were included. Results: A total of 858 ELBW infants were reviewed, 28 SIP cases (GA 25.3 ± 2.1 weeks, BW 735 ± 167 g) were identified, and 84 PSM-controls were matched. The SIP cases received hydrocortisone (25% (7/28) vs. 9.5% (8/84), p = 0.037) and combined inotropic agents (17.9% (5/28) vs. 2.4% (2/84), p = 0.020) to a significantly greater extent. No differences were observed in the use of other medications. In logistic regression, the use of hydrocortisone and combined inotropes remained independent risks for SIP, with ORs (95% CIs) of 3.4 (1.1-10.9) and 2.1 (1.2-3.8), respectively. Conclusions: This first PSM-based study supported postnatal hydrocortisone and combined inotrope use as independent risks for SIP in ELBW infants. Clinicians should be aware of these risks and remain vigilant for SIP when administering hydrocortisone and inotropes.

The phenotype of necrotizing enterocolitis correlates with distinct changes of intestinal junctional proteins

Necrotizing enterocolitis (NEC) is a major cause of mortality in preterm infants. Its pathophysiology remains poorly understood but intestinal epithelial barrier dysfunction contributes to the disease. We characterized junctional proteins in intestinal specimens from preterm infants. Samples from 27 patients with NEC and 20 patients with focal intestinal perforation (FIP) from the center of the specimens (affected) or the macroscopically healthy resection margins whenever available (non-affected) were collected. NEC patients displayed higher mortality and more commonly occurrence of impaired glucose homeostasis, patent ductus arteriosus, anemia and antibiotic treatment compared to FIP patients. Discrimination between NEC and FIP was not possible in affected areas based on H.E. staining using a newly developed scoring system. Immunofluorescence revealed reduced Claudin-3 in affected NEC samples and decreased Claudin-4 in affected FIP and all NEC samples. E-cadherin and Desmoglein-2 were reduced in a subgroup of the affected NEC samples. Plakophilin-2 was decreased in intestine affected by FIP and unaffected intestine in patients with NEC. In affected areas of NEC, Plakophilin-2 was completely lost. Plakoglobin reduction in affected NEC samples correlated with poor survival. This study provides novel insights into changes of junctional proteins in NEC, suggesting Claudin-3 and Plakophilin-2 as diagnostic markers to differentiate FIP from NEC and reduced Plakoglobin as a prognostic marker.

Understanding necrotizing enterocolitis endotypes and acquired intestinal injury phenotypes from a historical and artificial intelligence perspective

Necrotizing enterocolitis (NEC) remains a devastating disease in preterm and term neonates. Despite significant progress made in understanding NEC pathogenesis over the last 50 years, the inability of current definitions to discriminate the various pathophysiological processes underlying NEC has led to an umbrella term that limits clinical and research progress. In this mini review, we provide a historical perspective on how NEC definitions and pathogenesis have evolved to our current understanding of NEC endotypes. We also discuss how artificial intelligence-based approaches are influencing our knowledge of risk-factors, classification and prognosis of NEC and other neonatal intestinal injury phenotypes.

Neonatal Necrotizing Enterocolitis: An Update on Pathophysiology, Treatment, and Prevention

Necrotizing enterocolitis (NEC) is a life-threatening disease predominantly affecting premature and very low birth weight infants resulting in inflammation and necrosis of the small bowel and colon and potentially leading to sepsis, peritonitis, perforation, and death. Numerous research efforts have been made to better understand, treat, and prevent NEC. This review explores a variety of factors involved in the pathogenesis of NEC (prematurity, low birth weight, lack of human breast milk exposure, alterations to the microbiota, maternal and environmental factors, and intestinal ischemia) and reports treatment modalities surrounding NEC, including pain medications and common antibiotic combinations, the rationale for these combinations, and recent antibiotic stewardship approaches surrounding NEC treatment. This review also highlights the effect of early antibiotic exposure, infections, proton pump inhibitors (PPIs), and H2 receptor antagonists on the microbiota and how these risk factors can increase the chances of NEC. Finally, modern prevention strategies including the use of human breast milk and standardized feeding regimens are discussed, as well as promising new preventative and treatment options for NEC including probiotics and stem cell therapy.