Necrotizing enterocolitis among neonates in the United States

Necrotizing enterocolitis in monochorionic twins: Insights from an identical twin model

Necrotizing enterocolitis (NEC) is a major cause of neonatal morbidity and mortality in preterm neonates, yet its pathophysiology remains unclear. The aim of this study is to evaluate risk factors for NEC using an identical twin model. In this case-control study, all monochorionic twin pairs born in our center in 2002-2020 were retrospectively reviewed for NEC. Potential risk factors for NEC were studied. For within-pair comparison, outcomes were compared between affected and unaffected twins. Within-pair analyses showed that the twin with NEC had a lower birth weight compared to its unaffected co-twin (1100 (913-1364) vs. 1339 (1093-1755) grams). Median gestational age at birth and birth weight were lower in twin pairs in the NEC-group compared to the no-NEC group, 29.1 weeks (27.8-30.8) versus 33.6 (30.7-36.0) and 1221 g (1010-1488) versus 1865 (1356-2355) respectively. Twin pregnancies in the NEC-group were more often complicated by twin-to-twin transfusion syndrome compared to the no-NEC-group (70 % (14/20) vs. 49 % (472/962)), particularly when treated with amnioreduction. This unique population of identical twins confirms that preterm neonates with a relatively lower birth weight are more prone to develop NEC compared to their co-twin, regardless of other genetic, maternal and obstetrical factors.

Mortality and extrauterine growth restriction of necrotizing enterocolitis in very preterm infants with heart disease: a multi-center cohort study

Congenital heart disease (CHD) and patent ductus arteriosus (PDA) are risk factors of necrotizing enterocolitis (NEC) in infants. However, it is unclear whether the prognosis of NEC is different between very preterm infants (VPIs) with and without heart diseases. This was an observational cohort study that enrolled VPIs (born between 24+0 and 31+6 weeks) admitted to 79 tertiary neonatal intensive care units (NICU) in the Chinese Neonatal Network (CHNN) between 2019 and 2021. The exposure was CHD or isolated PDA, and VPIs with NEC were divided into three groups: complicated with CHD, with isolated PDA, and without heart diseases. The primary outcomes were NEC-related adverse outcomes (death or extrauterine growth restriction (EUGR)). Logistic regression models were used to adjust potential confounders and calculate the odds ratios (ORs) and 95% confidential intervals (CIs) for each outcome. A total of 1335 VPIs with NEC were enrolled in this study, including 65 VPIs with CHD and 406 VPIs with isolated PDA. The VPIs with heart diseases had smaller gestational ages and lower body weights at birth, more antenatal steroids use, and requiring inotrope prior to the onset of NEC. While suffering from NEC, there was no significant increased risks in NEC-related death in VPIs with either CHD (adjusted OR [aOR]: 1.10; 95% CI: 0.41-2.50) or isolated PDA (aOR: 1.25; 95% CI 0.82-1.87), and increased risks in EUGR were identified in either survival VPIs with CHD (aOR: 2.35; 95% CI: 1.31-4.20) or isolated PDA (aOR: 1.53; 95% CI: 1.16-2.01) in survivors. The composite outcome (death or EUGR) was also more often observed in VPIs with either CHD (aOR: 2.07; 95% confidence interval [CI]: 1.20-3.60) or isolated PDA (aOR: 1.51; 95% CI: 1.17-1.94) than that without heart diseases. VPIs with either CHD or isolated PDA were associated with significantly prolonged duration of fasting, extended time to achieve full enteral feeding, and longer ventilation duration and hospitalization duration. Similar characteristics were also seen in VPIs with isolated PDA, with the exception that VPIs with CHD are more likely to undergo surgical intervention and maintain a prolonged fast after NEC.     Conclusion: In VPIs with NEC, CHD and isolated PDA are associated with an increased risk in worse outcomes. We recommend that VPIs with cardiac NEC be managed with aggressive treatment and nutrition strategies to prevent EUGR. What is Known: • CHD and PDA are risk factors for NEC in infants, which can lead to adverse outcomes such as death and EUGR. • NEC in infants with heart disease differs clinically from that in infants without heart disease and should be recognized as a separate disease process. What is New: • CHD and isolated PDA are associated with increased risks of EUGR in VPIs with NEC. • Risk factors associated with VPIs with cardiac NEC suggested these patients should be managed with aggressive treatment and nutrition strategies to adverse outcomes.

Machine learning-based analysis for prediction of surgical necrotizing enterocolitis in very low birth weight infants using perinatal factors: a nationwide cohort study

Early prediction of surgical necrotizing enterocolitis (sNEC) in preterm infants is important. However, owing to the complexity of the disease, identifying infants with NEC at a high risk for surgical intervention is difficult. We developed a machine learning (ML) algorithm to predict sNEC using perinatal factors obtained from the national cohort registry of very low birth weight (VLBW) infants. Data were collected from the medical records of 16,385 VLBW infants registered in the Korean Neonatal Network (KNN). Infants who underwent surgical intervention were identified with sNEC, and infants who received medical treatment, with medical NEC (mNEC). We used 38 variables, including maternal, prenatal, and postnatal factors that were obtained within 1 week of birth, for training. A total of 1085 patients had NEC (654 with sNEC and 431 with mNEC). VLBW infants showed a higher incidence of sNEC at a lower gestational age (GA) (p < 0.001). Our proposed ensemble model showed an area under the receiver operating characteristic curve of 0.721 for sNEC prediction.    Conclusion: Proposed ensemble model may help predict which infants with NEC are likely to develop sNEC. Through early prediction and prompt intervention, prognosis of sNEC may be improved. What is Known: • Machine learning (ML)-based techniques have been employed in NEC research for prediction, diagnosis, and prognosis, with promising outcomes. • While most studies have utilized abdominal radiographs and clinical manifestations of NEC as data sources, and have demonstrated their usefulness, they may prove weak in terms of early prediction. What is New: • We analyzed the perinatal factors of VLBW infants acquired within 7 days of birth and used ML-based analysis to identify which infants with NEC are vulnerable to clinical deterioration and at high risk for surgical intervention using nationwide cohort data.

Timing and risk factors associated with acute kidney injury in infants with necrotizing enterocolitis

OBJECTIVE

To evaluate the prevalence, onset, risk factors, and mortality associated with acute kidney injury (AKI) in infants with necrotizing enterocolitis (NEC).

DESIGN/METHODS

Retrospective study at 2 centers in infants with NEC, with/without AKI. AKI assessed by serum creatinine and urine output. Statistical tests used included t, Mann-Whitney U, Chi-square, and Fisher Exact tests.

RESULTS

Among 80 eligible infants with NEC, 56 (70%) had AKI. Median onset of NEC was day 15, with median AKI onset two days (IQR, -5.75 to 0) prior to NEC onset. Vasopressors were significantly more likely to be used in infants with NEC and AKI (p = 0.009). Increased mortality (p = 0.01) was noted in infants with NEC and AKI.

CONCLUSIONS

The onset of AKI mostly precedes NEC onset, with moderate to severe AKI more prevalent than the milder form in infants with NEC. These infants are significantly more likely to be hemodynamically unstable and have increased mortality.

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.

Analysis of Postoperative Outcomes and Extrauterine Growth Retardation in Preterm Infants with Necrotizing Enterocolitis: A Retrospective Study

OBJECTIVE

 High mortality and extrauterine growth retardation (EUGR) remain serious problems in preterm infants after necrotizing enterocolitis (NEC) surgery. This study investigated the risk factors for mortality and EUGR in preterm infants after NEC surgery.

STUDY DESIGN

 The risk factors were analyzed retrospectively by univariate analysis and multivariate logistic regression analysis in 52 preterm infants, who underwent NEC surgery and were hospitalized in neonatology department of Shanghai Children's Hospital between May 2014 and December 2021. Patients were divided into survival and death groups. Survivors were divided into two groups according to whether EUGR occurred when they achieved full enteral feeding after surgery.

RESULTS

 The mortality of preterm infants after NEC surgery was 26.9% (14/52). About 55.3% (21/38) of survivors developed postoperative EUGR. (1) Age at surgery, proportion of shock, and intestinal perforation differed significantly between the survival and death groups (p = 0.001, 0.005, and 0.02, respectively). Shock (p = 0.02, odds ratio [OR] = 8.86, 95% confidence interval [CI]: 1.43-55.10) and intestinal perforation (p = 0.03, OR = 6.12, 95% CI: 1.16-32.41) were significant risk factors for death. (2) Compared with the non-EUGR group, proportion of preoperative EUGR, postoperative 1-week calories, and parenteral nutrition time differed significantly in EUGR group (p = 0.001, 0.01, and 0.04, respectively). Preoperative EUGR (p = 0.02, OR = 18.63, 95%CI: 1.77-196.42) was a significant risk factor for postoperative EUGR.

CONCLUSION

 Shock and intestinal perforation are significant risk factors for death in preterm infants after NEC surgery. Survivors are prone to EUGR, and preoperative EUGR is a significant risk factor. In addition, adequate caloric intake and achievement of full enteral feeding as soon as possible may be beneficial to improve EUGR of preterm infants after NEC surgery.

KEY POINTS

· Shock and intestinal perforation are risk factors for death in preterm infants after NEC surgery.. · Preoperative EUGR is a risk factor for postoperative EUGR in preterm infants after NEC surgery.. · Active correction of shock and avoiding intestinal perforation may help improve the outcomes..

Necrotizing enterocolitis: current understanding of the prevention and management

Necrotizing enterocolitis (NEC) is one of the diseases in neonates, with a high morbidity and mortality rate, especially in preterm infants. This review aimed to briefly introduce the latest epidemiology, susceptibility factors, and clinical diagnosis and presentation of NEC. We also organized new prevention strategies by risk factors according to different pathogeneses and then discussed new treatment methods based on Bell's staging and complications, and the classification of mild to high severity based on clinical and imaging manifestations. Such a generalization will help clinicians and researchers to gain a deeper understanding of the disease and to conduct more targeted classification, grading prevention, and exploration. We focused on prevention and treatment of the early and suspected stages of NEC, including the discovery of novel biomarkers and drugs to control disease progression. At the same time, we discussed its clinical application, future development, and shortcomings.

Cholestasis is associated with a higher rate of complications in both medical and surgical necrotizing enterocolitis

OBJECTIVE

To evaluate the relationship between cholestasis and outcomes in medical and surgical necrotizing enterocolitis (NEC).

STUDY DESIGN

A retrospective analysis of prospectively collected data from 1472 infants with NEC [455 medical (mNEC) and 1017 surgical (sNEC)] from the Children's Hospital Neonatal Database.

RESULTS

The prevalence of cholestasis was lower in mNEC versus sNEC (38.2% vs 70.1%, p < 0.001). In both groups, cholestasis was associated with lower birth gestational age [mNEC: OR 0.79 (95% CI 0.68-0.92); sNEC: OR 0.86 (95% CI 0.79-0.95)] and increased days of parenteral nutrition [mNEC: OR 1.08 (95% CI 1.04-1.13); sNEC: OR 1.01 (95% CI 1.01-1.02)]. For both groups, the highest direct bilirubin was associated with the composite outcome mortality or length of stay >75th percentile [mNEC: OR 1.21 (95% CI 1.06-1.38); sNEC: OR 1.06 (95% CI 1.03-1.09)].

CONCLUSION

Cholestasis with both medical NEC and surgical NEC is associated with adverse patient outcomes including increased mortality or extreme length of stay.

Novel pathogenic GATA6 variant associated with congenital heart disease, diabetes mellitus and necrotizing enterocolitis

BACKGROUND

Pathogenic GATA6 variants have been associated with congenital heart disease (CHD) and a spectrum of extracardiac abnormalities, including pancreatic agenesis, congenital diaphragmatic hernia, and developmental delay. However, the comprehensive genotype-phenotype correlation of pathogenic GATA6 variation in humans remains to be fully understood.

METHODS

Exome sequencing was performed in a family where four members had CHD. In vitro functional analysis of the GATA6 variant was performed using immunofluorescence, western blot, and dual-luciferase reporter assay.

RESULTS

A novel, heterozygous missense variant in GATA6 (c.1403 G > A; p.Cys468Tyr) segregated with affected members in a family with CHD, including three with persistent truncus arteriosus. In addition, one member had childhood onset diabetes mellitus (DM), and another had necrotizing enterocolitis (NEC) with intestinal perforation. The p.Cys468Tyr variant was located in the c-terminal zinc finger domain encoded by exon 4. The mutant protein demonstrated an abnormal nuclear localization pattern with protein aggregation and decreased transcriptional activity.

CONCLUSIONS

We report a novel, familial GATA6 likely pathogenic variant associated with CHD, DM, and NEC with intestinal perforation. These findings expand the phenotypic spectrum of pathologic GATA6 variation to include intestinal abnormalities.

IMPACT

Exome sequencing identified a novel heterozygous GATA6 variant (p.Cys468Tyr) that segregated in a family with CHD including persistent truncus arteriosus, atrial septal defects and bicuspid aortic valve. Additionally, affected members displayed extracardiac findings including childhood-onset diabetes mellitus, and uniquely, necrotizing enterocolitis with intestinal perforation in the first four days of life. In vitro functional assays demonstrated that GATA6 p.Cys468Tyr variant leads to cellular localization defects and decreased transactivation activity. This work supports the importance of GATA6 as a causative gene for CHD and expands the phenotypic spectrum of pathogenic GATA6 variation, highlighting neonatal intestinal perforation as a novel extracardiac phenotype.

Clinical Dilemma Involving Treatments for Very Low-Birth-Weight Infants and the Potential Risk of Necrotizing Enterocolitis: A Narrative Literature Review

Necrotizing enterocolitis (NEC) is a critical gastrointestinal emergency with substantial morbidity and mortality risks, especially for very low-birth-weight (VLBW) infants, and unclear multifactorial pathophysiology. Whether common treatments for VLBW infants increase the NEC risk remains controversial. Indomethacin (utilized for patent ductus arteriosus) offers benefits but is concerning because of its vasoconstrictive impact on NEC susceptibility. Similarly, corticosteroids used to treat bronchopulmonary dysplasia may increase vulnerability to NEC by compromising immunity and altering the mesenteric blood flow. Histamine-2 receptor blockers (used to treat gastric bleeding) may inadvertently promote NEC by affecting bacterial colonization and translocation. Doxapram (used to treat apnea) poses a risk of gastrointestinal disturbance via gastric acid hypersecretion and circulatory changes. Glycerin enemas aid meconium evacuation but disrupt microbial equilibrium and trigger stress-related effects associated with the NEC risk. Prolonged antibiotic use may unintentionally increase the NEC risk. Blood transfusions for anemia can promote NEC via interactions between the immune response and ischemia-reperfusion injury. Probiotics for NEC prevention are associated with concerns regarding sepsis and bacteremia. Amid conflicting evidence, this review unveils NEC risk factors related to treatments for VLBW infants, offers a comprehensive overview of the current research, and guides personalized management strategies, thereby elucidating this clinical dilemma.

Breastfeeding and human milk in the NICU: From birth to discharge

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

The incidence and modifiable risk factors for necrotizing enterocolitis in preterm infants: a retrospective cohort study

OBJECTIVES

To evaluate the incidence and modifiable risk factors for Necrotizing enterocolitis (NEC) in preterm infants born at ≤32 weeks of gestation weighing <1500 grams, at a private tertiary care hospital in Kenya.

MATERIALS AND METHODS

This retrospective cohort study was conducted at the Aga Khan University Hospital Neonatal Intensive Care Unit (NICU). Preterm infants born at ≤ 32 weeks' gestation and weighing <1500 grams admitted to NICU between 2009 and 2019, were recruited into the study. The primary outcome was NEC Bell Stage IIa-IIIb based on Modified Bell's criteria. Maternal and neonatal characteristics were evaluated. The association between variables of interest and NEC was determined using logistic regression analysis and the incidence of NEC for the study period was calculated.

RESULTS

A total of 261 charts of infants born at ≤ 32 weeks' gestation, weighing <1500 were reviewed, and 200 charts met the inclusion criteria. Fifteen preterm infants developed the primary outcome of interest: NEC Stage ≥2a within the first 30 days of admission. The overall incidence of NEC for the study period was 7.5%. Three risk factors were identified as significantly associated with NEC on multivariate logistic regression analysis: antenatal exposure to steroids (OR = 0.056 CI = 0.003-0.964 p = 0.047), cumulative duration of exposure to invasive mechanical ventilation (OR = 2.172 CI = 1.242-3.799 p = 0.007) and cumulative duration of exposure to umbilical vein catheter (OR = 1.344 CI = 1.08-1.672 p = 0.008).

CONCLUSIONS

The overall incidence for the study period of NEC Stage ≥ II a was 7.5%. Exposure to antenatal steroids, duration of mechanical ventilation, and duration of umbilical vein catheterization were three independent modifiable risk factors for NEC Stage II a-Stage III b.

Novel scoring system for early diagnosis of necrotizing enterocolitis: integrating clinical and laboratory data with urinary caveolin-1 levels

Introduction

Necrotizing enterocolitis (NEC) poses a significant threat to preterm infants, with nonspecific early manifestations complicating timely diagnosis. Therefore, this study aimed to develop a novel scoring system for early diagnosis of NEC, incorporating clinical and laboratory data with urinary caveolin-1 levels.

Material and methods

A single-center prospective cohort study was conducted at a tertiary hospital in East Java, Indonesia. NEC diagnosis was established by Bell's criteria and proven gut dysbiosis. Urinary levels of claudin-2, caveolin-1, and epidermal growth factor (EGF) were assessed as potential indicators of tight junction disruption. The selected urine biomarker cutoff value was determined using symbolic classification analysis and combined with clinical and laboratory parameters from Bell's criteria to create an NEC scoring system, validated with the Aiken index. Sensitivity and specificity analyses were performed.

Results

Thirty-four neonates, comprising NEC, preterm non-NEC, and term infants, were included. qPCR analysis highlighted elevated Klebsiella, Lactobacillus, Clostridium, and Bacteroides levels in NEC patients, indicating a gut dysbiosis trend. Among 3 biomarkers, caveolin-1 ≥ 17.81 ng/dl on day 3 demonstrated 72.86% negative predictive value and 87.50% positive predictive value. The combined scoring system which comprised abdominal cellulitis, distension, radiology, advanced resuscitation at birth, prematurity or low birthweight, platelet count, sepsis, orogastric retention, metabolic acidosis and caveolin-1 findings exhibited an AUC of 0.922 (95% CI: 0.81-1.00, p < 0.001), with ≥ 1.81 as the cutoff, offering 93% sensitivity and 94% specificity.

Conclusions

Urine caveolin-1 on day 3 signifies enterocyte tight junction damage and the acute phase of NEC in premature infants. The proposed scoring system demonstrates good performance in predicting NEC incidence in preterm infants.

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

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

Necrotizing enterocolitis: recent advances in treatment with translational potential

Necrotizing enterocolitis (NEC) is one of the most prevalent and devastating gastrointestinal disorders in neonates. Despite advances in neonatal care, the incidence and mortality due to NEC remain high, highlighting the need to devise novel treatments for this disease. There have been a number of recent advancements in therapeutic approaches for the treatment of NEC; these involve remote ischemic conditioning (RIC), stem cell therapy, breast milk components (human milk oligosaccharides, exosomes, lactoferrin), fecal microbiota transplantation, and immunotherapy. This review summarizes the most recent advances in NEC treatment currently underway as well as their applicability and associated challenges and limitations, with the aim to provide new insight into the paradigm of care for NEC worldwide.

Human Bone Marrow-Derived Mesenchymal Stromal Cells Reduce the Severity of Experimental Necrotizing Enterocolitis in a Concentration-Dependent Manner

Necrotizing enterocolitis (NEC) is a devastating gut disease in preterm neonates. In NEC animal models, mesenchymal stromal cells (MSCs) administration has reduced the incidence and severity of NEC. We developed and characterized a novel mouse model of NEC to evaluate the effect of human bone marrow-derived MSCs (hBM-MSCs) in tissue regeneration and epithelial gut repair. NEC was induced in C57BL/6 mouse pups at postnatal days (PND) 3-6 by (A) gavage feeding term infant formula, (B) hypoxia/hypothermia, and (C) lipopolysaccharide. Intraperitoneal injections of PBS or two hBM-MSCs doses (0.5 × 10⁶ or 1 × 10⁶) were given on PND2. At PND 6, we harvested intestine samples from all groups. The NEC group showed an incidence of NEC of 50% compared with controls (p < 0.001). Severity of bowel damage was reduced by hBM-MSCs compared to the PBS-treated NEC group in a concentration-dependent manner, with hBM-MSCs (1 × 10⁶) inducing a NEC incidence reduction of up to 0% (p < 0.001). We showed that hBM-MSCs enhanced intestinal cell survival, preserving intestinal barrier integrity and decreasing mucosal inflammation and apoptosis. In conclusion, we established a novel NEC animal model and demonstrated that hBM-MSCs administration reduced the NEC incidence and severity in a concentration-dependent manner, enhancing intestinal barrier integrity.

Updates and recommendations on the surgical management of NEC

Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature.

Preventing severe necrotizing enterocolitis: Propensity score analysis of interventions associated with surgical NEC or NEC-associated death

PURPOSE

To determine what modifiable interventions used in the neonatal intensive care unit (NICU) are associated with severe necrotizing enterocolitis (NEC) requiring surgical intervention.

METHODS

A retrospective review of patients treated for NEC at a tertiary hospital from 1991 to 2016 was performed. Patient characteristics were used to calculate propensity scores for likelihood of exposure to seven interventions: enteral feeds, use of glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), antacids, antibiotics, or umbilical arterial (UAC) and venous catheters (UVC). Conditional logistic regression was used to compare the odds of having surgical NEC if exposed to each treatment.

RESULTS

We included 195 NEC patients: 69 severe NEC managed with surgery and 126 non-severe NEC managed medically. After propensity score matching based on birth characteristics, exposure to glucocorticoids (OR 5.21, 95%CI: 1.62, 16.70), NSAIDs (OR 4.87, 95%CI: 1.67, 14.17), UVC (OR 2.53 (95%CI: 1.19, 5.73), and UAC (OR 4.91, 95%CI: 2.12, 11.37) were associated with surgical NEC in separate conditional logistic regression analyses. Including these treatments in a second round of propensity matching and conditional logistic regression revealed that glucocorticoids (OR 2.99, 95%CI: 1.01, 8.88), NSAIDs (OR 3.97, 95%CI: 1.41, 11.19), UVC (OR 3.07, 95%CI: 1.46, 6.48), and UAC (OR 5.10, 95%CI: 2.10, 12.36) were still associated with surgical NEC.

CONCLUSION

After controlling for birth confounders and common NICU supportive interventions, use of glucocorticoids, NSAIDs and umbilical catheters independently increased the odds of developing severe NEC requiring surgical intervention.

LEVEL-OF-EVIDENCE RATING

Case-control, Level III evidence.

Impact of concomitant necrotizing enterocolitis on mortality in very low birth weight infants with intraventricular hemorrhage

OBJECTIVE

To evaluate the impact of necrotizing enterocolitis (NEC) on mortality in very low birth weight (VLBW) infants with intraventricular hemorrhage (IVH).

STUDY DESIGN

Data were collected on VLBW infants born 2014-2018 at Vermont Oxford Network (VON) centers. NEC and IVH were categorized by severity. Adjusted risk ratios (ARR) for in-hospital mortality were calculated.

RESULTS

This study included 187 187 VLBW infants. Both medical and surgical NEC increased mortality risk compared to those without NEC. Stratification by IVH severity modified this effect (no IVH: ARR 3.04 (95%CI 2.74-3.38) for medical NEC and 4.17 (3.84-4.52) for surgical NEC; mild IVH: ARR 2.14 (1.88-2.44) for medical NEC and 2.49 (2.24-2.78) for surgical NEC; severe IVH: ARR 1.14 (1.03-1.26) for medical NEC and 1.10 (1.02-1.18) for surgical NEC).

CONCLUSION

The relative impact of NEC on mortality decreased as IVH severity increased. Given the frequent coexistence of NEC and IVH, these data inform multidisciplinary management of these complex patients.

Surgery or comfort care for neonates with surgical necrotizing enterocolitis: Lessons learned from behavioral artificial intelligence technology

Background

Critical decision making in surgical necrotizing enterocolitis (NEC) is highly complex and hard to capture in decision rules due to case-specificity and high mortality risk. In this choice experiment, we aimed to identify the implicit weight of decision factors towards future decision support, and to assess potential differences between specialties or centers.

Methods

Thirty-five hypothetical surgical NEC scenarios with different factor levels were evaluated by neonatal care experts of all Dutch neonatal care centers in an online environment, where a recommendation for surgery or comfort care was requested. We conducted choice analysis by constructing a binary logistic regression model according to behavioral artificial intelligence technology (BAIT).

Results

Out of 109 invited neonatal care experts, 62 (57%) participated, including 45 neonatologists, 16 pediatric surgeons and one neonatology physician assistant. Cerebral ultrasound (Relative importance = 20%, OR = 4.06, 95% CI = 3.39-4.86) was the most important factor in the decision surgery versus comfort care in surgical NEC, nationwide and for all specialties and centers. Pediatric surgeons more often recommended surgery compared to neonatologists (62% vs. 57%, p = 0.03). For all centers, cerebral ultrasound, congenital comorbidity, hemodynamics and parental preferences were significant decision factors (p < 0.05). Sex (p = 0.14), growth since birth (p = 0.25), and estimated parental capacities (p = 0.06) had no significance in nationwide nor subgroup analyses.

Conclusion

We demonstrated how BAIT can analyze the implicit weight of factors in the complex and critical decision for surgery or comfort care for (surgical) NEC. The findings reflect Dutch expertise, but the technique can be expanded internationally. After validation, our choice model/BAIT may function as decision aid.

Current and future methods of probiotic therapy for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a complex intestinal disease that primarily affects premature neonates. Given its significant mortality and morbidity, there is an urgent need to develop improved prophylactic measures against the disease. One potential preventative strategy for NEC is the use of probiotics. Although there has been significant interest for decades in probiotics in neonatal care, no clear guidelines exist regarding which probiotic to use or for which patients, and no FDA-approved products exist on the market for NEC. In addition, there is lack of agreement regarding the benefits of probiotics in neonates, as well as some concerns about the safety and efficacy of available products. We discuss currently available probiotics as well as next-generation probiotics and novel delivery strategies which may offer an avenue to capitalize on the benefits of probiotics, while minimizing the risks. Thus, probiotics may still prove to be an effective prevention strategy for NEC, although further product development and research is needed to support use in the preterm population.

Outcomes for necrotising enterocolitis (NEC) in babies born at the threshold of viability: a case-control study

BACKGROUND

The threshold for active management of babies born prematurely in the UK is currently 22 weeks. The optimal management strategy for necrotising enterocolitis (NEC) in babies born at or near this threshold remains unclear.

AIM

To review our institutional experience of babies born <24 weeks diagnosed with NEC, identify risk factors for NEC, and compare outcomes with a control cohort.

METHODS

All infants born <24 weeks gestation January 2015-December 2021 were identified. Babies diagnosed with NEC were defined as cases and babies with no NEC diagnosis as controls. Patient demographics, clinical features, complications and outcomes were extracted from the medical record and compared between cases and controls.

RESULTS

Of 56 babies, 31 (55.3%) were treated for NEC. There was no difference in NEC-specific risk factors between cases and controls. 17 babies (30.4%) underwent surgery, of these, 11/17 (64.7%) presented with a C reactive protein rise and 11/17 (64.7%) a fall in platelet count. Pneumatosis intestinalis (3/17 (17.7%)) or pneumoperitoneum (3/17 (17.7%)) were present in only a minority of cases. Abdominal ultrasound demonstrated intestinal perforation in 8/8 cases. The surgical complication rate was 5/17 (29.4%). There was no difference in the incidence of intraventricular haemorrhage, periventricular leukomalacia and survival to discharge between the groups.

CONCLUSIONS

The diagnosis of NEC in infants born <24 weeks gestation is challenging with inconsistent clinical and radiological features. Ultrasound scanning is a useful imaging modality. Mortality was comparable regardless of a diagnosis of NEC. Low gestational age is not a contraindication to surgical intervention in NEC.

Racial disparities in the development of comorbid conditions after preterm birth: A narrative review

Despite recognition and attempts to reduce racial disparities in perinatal outcomes, Black infants are still disproportionately represented among those who are born preterm. Postnatal investigations of racial disparities in comorbidities and outcomes after preterm birth are increasing, although their results and interpretations are conflicting. In the present review, we 1.) identify important methodological limitations of that literature 2.) summarize the conflicting literature investigating racial disparities, specifically Black-white differences, in postnatal comorbidities and outcomes after preterm birth 3.) describe mechanisms by which racism operates to contextualize our understanding to inform future work to actively reduce disparities in preterm birth and subsequently, its complications.

Long-Term Outcome of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

OBJECTIVES

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are complications in preterm infants associated with high morbidity, mortality, impaired growth, and neurodevelopmental (ND) outcomes. Few studies have reported growth or ND outcomes of infants born extremely preterm with NEC/SIP beyond early childhood. Here, we compared anthropometric and ND outcomes, at 10 and 15 years, for children with medical NEC, surgical NEC, SIP, and neither NEC nor SIP.

METHODS

Participants from the prospective longitudinal extremely low gestational age newborns study were evaluated at ages 10 and 15 years for anthropometrics, neurocognition, attention-deficit/hyperactivity disorder, epilepsy, and gross motor function.

RESULTS

At age 10 years, 889 children were followed-up (medical NEC = 138, surgical NEC = 33, SIP = 29, no NEC/SIP = 689), and 694 children were followed up-at 15 years. Children with medical NEC had similar weight, BMI, height, and head circumference compared with controls at both 10 and 15 years. At 15 years, children with surgical NEC had lower weight z-score (adjusted β: -0.75, 95% confidence interval [CI]: -1.25 to -0.25), lower BMI z-score (adjusted β: -0.55, 95% CI: -1.09 to -0.01), and lower height z-score (adjusted β: -0.65, 95% CI: -1.16 to -0.14). Children with SIP had lower weight and height z-scores at age 10 years when adjusted for sample attrition, but these differences were not significant when adjusted for confounders. We observed no differences in long-term ND outcomes.

CONCLUSIONS

Surgical NEC- and SIP-associated growth impairment may persist through late childhood. ND outcomes among school-aged children born extremely preterm with any NEC or SIP are no different from children without NEC/SIP.

Peptide Tat(48-60) YVEEL protects against necrotizing enterocolitis through inhibition of toll-like receptor 4-mediated signaling in a phosphatidylinositol 3-kinase/AKT dependent manner

Necrotizing enterocolitis (NEC) is a catastrophic disease largely occurring in preterm infants, and toll-like receptor 4 (TLR4) has been implicated in its pathogenesis. The current therapeutic strategies for NEC are, however, far from optimal. In the present study, a whey-derived antioxidative peptide conjugated with a cell-penetrating TAT [^{Tat (48-60)} YVEEL] was prepared to endow it with enhanced cell uptake capability and bioavailability. The protective effect of ^{Tat (48-60)} YVEEL on experimental NEC was evaluated both in vitro and in vivo. Inhibition of TLR4-mediated signaling by ^{Tat (48-60)} YVEEL was assessed in FHC and IEC-6 enterocytes, neonatal rat model of NEC, and the mechanism underlying this effect was determined. ^{Tat (48-60)} YVEEL significantly inhibited TLR4-mediated expression of pro-inflammatory cytokines, p65 nuclear translocation and restored the impaired enterocyte migration in cultured enterocytes. In addition, ^{Tat (48-60)} YVEEL administration strikingly increased the survival rate, and reduced the severity of NEC in rats through inhibition of TLR4-mediated signaling. These protective effects of ^{Tat (48-60)} YVEEL occurred in a PI3K/AKT dependent manner, as administration of PI3K activator Ys49 abrogated its protective effects. Combined with liposomes, ^{Tat (48-60)} YVEEL demonstrated longer retention in the intestines that better for potential clinical applications. These data demonstrate that ^{Tat (48-60)} YVEEL protects against NEC through inhibition of TLR4-mediated signaling in a PI3K/AKT dependent manner, and offer a potential therapeutic approach to this disease.

In vivo phenotyping of the microvasculature in necrotizing enterocolitis with multicontrast optical imaging

OBJECTIVE

Necrotizing enterocolitis (NEC) is the most prevalent gastrointestinal emergency in premature infants and is characterized by a dysfunctional gut microcirculation. Therefore, there is a dire need for in vivo methods to characterize NEC-induced changes in the structure and function of the gut microcirculation, that is, its vascular phenotype. Since in vivo gut imaging methods are often slow and employ a single-contrast mechanism, we developed a rapid multicontrast imaging technique and a novel analyses pipeline for phenotyping the gut microcirculation.

METHODS

Using an experimental NEC model, we acquired in vivo images of the gut microvasculature and blood flow over a 5000 × 7000 μm² field of view at 5 μm resolution via the following two endogenous contrast mechanisms: intrinsic optical signals and laser speckles. Next, we transformed intestinal images into rectilinear "flat maps," and delineated 1A/V gut microvessels and their perfusion territories as "intestinal vascular units" (IVUs). Employing IVUs, we quantified and visualized NEC-induced changes to the gut vascular phenotype.

RESULTS

In vivo imaging required 60-100 s per animal. Relative to the healthy gut, NEC intestines showed a significant overall decrease (i.e. 64-72%) in perfusion, accompanied by vasoconstriction (i.e. 9-12%) and a reduction in perfusion entropy (19%)within sections of the vascular bed.

CONCLUSIONS

Multicontrast imaging coupled with IVU-based in vivo vascular phenotyping is a powerful new tool for elucidating NEC pathogenesis.

Risk factors for necrotizing enterocolitis in preterm infants: a Meta analysis

OBJECTIVES

To systematically evaluate the risk factors for necrotizing enterocolitis (NEC) in preterm infants.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were searched for case-control studies and cohort studies on the risk factors for NEC in preterm infants published up to December 2021. RevMan 5.3 software was used to perform the Meta analysis.

RESULTS

A total of 38 studies were included (28 case-control studies and 10 cohort studies). The Meta analysis showed that maternal gestational diabetes (OR=2.96, P<0.001), intrahepatic cholestasis during pregnancy (OR=2.53, P<0.001), preeclampsia (OR=1.73, P=0.020), history of neonatal asphyxia (OR=2.13, P<0.001), low gestational age (OR=1.23, P=0.010), sepsis (OR=5.32, P<0.001), patent ductus arteriosus (OR=1.57, P=0.001), congenital heart disease (OR=3.78, P<0.001), mechanical ventilation (OR=2.23, P=0.020), history of antibiotic use (OR=1.07, P<0.001), use of vasopressors (OR=2.34, P=0.040), and fasting (OR=1.08, P<0.001) were risk factors for NEC in preterm infants, while cesarean section (OR=0.73, P=0.004), use of pulmonary surfactant (OR=0.43, P=0.008), and breastfeeding (OR=0.24, P=0.020) were protective factors against NEC.

CONCLUSIONS

Maternal gestational diabetes, intrahepatic cholestasis during pregnancy, preeclampsia, low gestational age, fasting, sepsis, patent ductus arteriosus, congenital heart disease, and histories of asphyxia, mechanical ventilation, antibiotic use, and use of vasopressors may increase the risk of NEC in preterm infants, while cesarean section, use of pulmonary surfactant, and breastfeeding may decrease the risk of NEC in preterm infants.

Effect of Maternal Diet on Any Necrotizing Enterocolitis in Neonates: A Randomized Double-Blind Study

Background: The etiology of necrotizing enterocolitis (NEC) is controversially discussed. One of the most recently proposed causes of NEC is an allergy to cow's milk protein. This study was designed to evaluate the effect of a maternal diet without bovine protein on the incidence of any NEC in very low birth weight (VLBW) infants. Materials and Methods: A pilot randomized controlled clinical trial was performed at Akbarabadi Hospital, Tehran, Iran, from December 2019 to July 2020, in women with VLBW infants. One hundred twenty mothers with VLBW neonates were randomly assigned to the intervention or the control group (60 in each). In the intervention group, mothers were given a dairy-free diet during the first 14 days after the newborn's onset of feeding. No special diet was given to the control group. The primary outcome of the study was the rate of any NEC in neonates, which was compared between groups. Any NEC was defined as Bell stage I or greater. Results: The minimum and maximum gestational ages were 26 and 33 weeks, respectively. The minimum birth weight of neonates was 700 g. The two groups did not differ significantly in terms of demographic and preinterventional clinical characteristics. Any NEC was reported in 0% and 10% (5/52) of neonates in the intervention and control groups, respectively; the difference was statistically significant (p = 0.028). The NEC symptoms began ∼34 days after birth. Four cases of NEC were classified as Bell stage I, and one was classified as Bell stage II. No statistical association was registered between sex, gestational age, birth weight, and the onset of feeding with the incidence of any NEC. Conclusion: The use of a cow's milk protein-free diet in mothers and exclusive breastfeeding in preterm VLBW infants may reduce the incidence of NEC. We recommend further studies with larger sample sizes in a multicenter setting. The study was registered at the Iranian Registry of Clinical Trials (IRCT20200415047086N1).

Feasibility of open abdomen surgery treatment for near fatal necrotizing enterocolitis in preterm infants

INTRODUCTION

Necrotizing Enterocolitis (NEC) remained a dramatic complication leading to death or neonatal morbidities in preterms. For some, Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome worsened the multi-organ failure. An open abdomen surgery could be an alternative to conventional surgical treatment to move beyond this stage.

OBJECTIVES

To retrospectively describe the clinical course, pre- and post-operative features of preterms suffering from severe NEC with IAH treated by open abdomen surgery and referred to our center from October 2007 to September 2019. Our secondary objective is to identify various risk factors for mortality in this population.

METHODS

Data on neonatal, clinical, biological, pre and post-operative features and outcome were collected. Univariate analyses were performed to compare their pre and post-operative features stratifying on outcome.

RESULTS

Among 29 included patients, 14 (48%) survived to discharge without short bowel syndrome. Death was associated with an earlier postnatal age at NEC (16.3 ± 9.1 versus 31.3 ± 25.9 days; p = 0.004) and followed a withdrawal of treatment in 60% of cases. Surgery was associated with a significant improvement of respiratory and hemodynamic features (decrease of mean ventilator pressure from 13.1 ± 5.4 to 11.3 ± 4.0 cmH2O, p < 0.001), oxygen requirement (mean FiO2 decreased from 65.0% ± 31.2 to 49.0% ± 24.6, p < 0.001) and inotropic score (from 38.6 ± 70.1 to 29.9 ± 64.3, p < 0.001). In the survival group, pre and post-operative findings exhibited a significant increase of serum lactate concentrations from 2.7 ± 1.6 to 11.0 ± 20.3 mmol/L (p = 0.02) but a similar pH.

CONCLUSION

Open abdomen surgery could be considered to rescue preterms with near fatal NEC. IAH and Abdominal Compartment Syndrome in these preterms should be investigated through further studies.

LEVEL OF EVIDENCE

Level III.

Predictive Factors for Surgical Intervention in Neonates with Necrotizing Enterocolitis: A Retrospective Study

Background

The current indications based on the clinicopathological parameters for predicting the need for surgery in neonatal necrotizing enterocolitis (NEC) are still limited. This study retrospectively analyzes the characteristics of neonatal NEC and aims to identify the risk factors for surgical intervention in NEC.

Methods

Data of the NEC cases from 2015 to 2019 were collected from our institution and divided into two groups: surgical group (n = 41) and conservative treatment group (n = 143). Clinical, physical, and laboratory measures were analyzed by univariate analysis and multivariate logistic regression. The diagnostic values and receiver operative characteristic (ROC) curve were used for the assessment.

Results

Univariate analysis identified significant differences between the surgical group and the conservative group in a series of clinical, physical, and laboratory measures (all p < 0.05). The results of multivariate logistic regression analysis showed that procalcitonin (adjusted OR: 167.1, 95% CI, 3.585–7,788.758, p = 0.009) and gestational age (adjusted OR: 0.85, 95% CI, 0.77–0.94, p = 0.001) were independent surgical indications for NEC. The results from ROC curve and diagnosis values demonstrated that procalcitonin [the area under the curve (AUC) = 0.864], CRP (AUC = 0.783) and fibrinogen (AUC = 0.720) had good predictive performance for surgical NEC.

Conclusions

The level of procalcitonin and gestational age were found to be independent surgical indications for neonates with NEC.

Remote ischemic conditioning in necrotizing enterocolitis: study protocol of a multi-center phase II feasibility randomized controlled trial

PURPOSE

Remote ischemic conditioning (RIC) is a maneuver involving brief cycles of ischemia reperfusion in an individual's limb. In the early stage of experimental NEC, RIC decreased intestinal injury and prolonged survival by counteracting the derangements in intestinal microcirculation. A single-center phase I study demonstrated that the performance of RIC was safe in neonates with NEC. The aim of this phase II RCT was to evaluate the safety and feasibility of RIC, to identify challenges in recruitment, retainment, and to inform a phase III RCT to evaluate efficacy.

METHODS

RIC will be performed by trained research personnel and will consist of four cycles of limb ischemia (4-min via cuff inflation) followed by reperfusion (4-min via cuff deflation), repeated on two consecutive days post randomization. The primary endpoint of this RCT is feasibility and acceptability of recruiting and randomizing neonates within 24 h from NEC diagnosis as well as masking and completing the RIC intervention.

RESULTS

We created a novel international consortium for this trial and created a consensus on the diagnostic criteria for NEC and protocol for the trial. The phase II multicenter-masked feasibility RCT will be conducted at 12 centers in Canada, USA, Sweden, The Netherlands, UK, and Spain. The inclusion criteria are: gestational age < 33 weeks, weight ≥ 750 g, NEC receiving medical treatment, and diagnosis established within previous 24 h. Neonates will be randomized to RIC (intervention) or no-RIC (control) and will continue to receive standard management of NEC. We expect to recruit and randomize 40% of eligible patients in the collaborating centers (78 patients; 39/arm) in 30 months. Bayesian methods will be used to combine uninformative prior distributions with the corresponding observed proportions from this trial to determine posterior distributions for parameters of feasibility.

CONCLUSIONS

The newly established NEC consortium has generated novel data on NEC diagnosis and defined the feasibility parameters for the introduction of a novel treatment in NEC. This phase II RCT will inform a future phase III RCT to evaluate the efficacy and safety of RIC in early-stage NEC.

Necrotizing enterocolitis: Bench to bedside approaches and advancing our understanding of disease pathogenesis

Necrotizing enterocolitis (NEC) is a devastating, multifactorial disease mainly affecting the intestine of premature infants. Recent discoveries have significantly enhanced our understanding of risk factors, as well as, cellular and genetic mechanisms of this complex disease. Despite these advancements, no essential, single risk factor, nor the mechanism by which each risk factor affects NEC has been elucidated. Nonetheless, recent research indicates that maternal factors, antibiotic exposure, feeding, hypoxia, and altered gut microbiota pose a threat to the underdeveloped immunity of preterm infants. Here we review predisposing factors, status of unwarranted immune responses, and microbial pathogenesis in NEC based on currently available scientific evidence. We additionally discuss novel techniques and models used to study NEC and how this research translates from the bench to the bedside into potential treatment strategies.

Characteristics of Surgical Necrotizing Enterocolitis: Is It Different from Medical Necrotizing Enterocolitis? A Single-Center Retrospective Study

(1) Background: Necrotizing enterocolitis (NEC) is one of the leading causes of death in newborns despite improvements in the care of critically ill neonates. Approximately 50–70% of the cases are managed by medical therapy. However, the remaining patients require surgical intervention. The purpose of our study was to analyze the factors associated with patients requiring surgical treatment compared to patients requiring only medical treatment; (2) Method: Patients diagnosed with necrotizing enterocolitis over a period of 14 years (January 2003–December 2016) in a single tertiary referral children’s hospital were retrospectively enrolled. Demographics and clinical data were collected through the medical record and were analyzed using Pearson’s χ2 test, t-tests, and linear regression; (3) Results: A total of 189 NEC patients were analyzed. In the surgical NEC group, gestational age was lower (p = 0.018), body weight at birth was lower (p = 0.034), comorbidity with respiratory distress syndrome (RDS) was higher (p = 0.005), the days of antibiotic use were greater (p = 0.014), the percentage of breast milk feeding was lower (p = 0.001), and the length of hospital stay was longer (p < 0.000). The in-hospital mortality between the two groups was not significantly different (p = 0.196). In multivariate logistic analysis, breast milk feeding remained less associated with surgical NEC (OR = 0.366, 95% CI: 0.164–0.817), whereas the length of hospital stay was more associated with surgical NEC (OR = 1.010, 95% CI: 1.001–1.019); (4) Conclusion: Comparing medical and surgical NEC, a significantly lower percentage of surgical NEC patients were fed breast milk and their hospital stays were longer.

Breast milk nutrients driving intestinal epithelial layer maturation via Wnt and Notch signaling: Implications for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is an often lethal, inflammatory disease of the preterm intestine. The underdeveloped immune system plays an important role; however, the initial trigger for NEC development is likely a damaged intestinal epithelial layer. We hypothesize that due to incomplete maturation of different epithelial cell lineages, nutrients and bacteria are able to damage the epithelial cells and cause the (immature) inflammatory response, food intolerance and malabsorption seen in NEC. Intestinal organoid research has shown that maturation of intestinal epithelial cell lineages is orchestrated by two key signaling pathways: Wnt and Notch. In NEC, these pathways are dysregulated by hyperactivation of Toll-like-receptor-4. Breastfeeding decreases the risk of developing NEC compared to formula milk. Here, we review the intricate link between breast milk components, Wnt and Notch signaling and intestinal epithelial maturation. We argue that (nutritional) interventions regulating these pathways may decrease the risk of NEC development in preterm infants.

Enteral Feeding and Necrotizing Enterocolitis: Does Time of First Feeds and Rate of Advancement Matter?

OBJECTIVE

The aim of the study was to determine if time to initial enteral feeding (EF) and rate of advancement are associated with necrotizing enterocolitis (NEC) or death.

METHODS

Secondary analysis of prospectively collected data of very-low-birth-weight infants (VLBWI: 400--1500 g) born in 26 NEOCOSUR centers between 2000 and 2014.

RESULTS

Among 12,387 VLBWI, 83.7% survived without NEC, 6.6% developed NEC and survived, and 9.6% had NEC and died or died without NEC (NEC/death). After risk adjustment, time to initial EF (median = 2 days) was not associated with NEC; however, delaying it was protective for NEC/death (odds ratio [OR] = 0.96; 95% confidence interval [CI] 0.93--0.99). A slower feeding advancement rate (FAR) was protective for NEC (OR = 0.97; 95% CI = 0.94-0.98) and for NEC/death (OR = 0.98; 95% CI = 0.96-0.99).

CONCLUSIONS

In VLBWI, there was no association between an early initial EF and NEC, although delaying it was associated with less NEC/death. A slower FAR was associated with lower risk of both outcomes.

Necrotizing enterocolitis and congenital heart disease

Necrotizing enterocolitis (NEC) remains a prominent surgical emergency among infant population, associated with a significant mortality, as well as various subsequent morbidities. Congenital heart disease (CHD) has an increased associated incidence with NEC in infant population. Recent research has provided insight into the pathophysiology of NEC in patients with CHD and how this differs from those without CHD. The deviation from normal circulatory physiology has a suggested association in the pathophysiology of NEC in CHD, which may have implications for the risk factors of NEC in infants with CHD, the effect on outcomes of NEC, and whether alternative approaches to management may need to be considered in comparison to classical NEC. This review aims to highlight studies that provide insight and awareness into the relationship between NEC and CHD, in order that clinicians may direct themselves more clearly toward optimal management for infants in this category.

Therapy for Apnoea of Prematurity: A Retrospective Study on Effects of Standard Dose and Genetic Variability on Clinical Response to Caffeine Citrate in Chinese Preterm Infants

INTRODUCTION

Apnoea of prematurity (AOP) is among the most common diagnoses in the neonatal intensive care unit. Caffeine treatment is a preferred treatment choice. However, neonatal caffeine therapy results in significant intersubject variability. This study aimed to determine the effects of plasma caffeine levels based on standard dose and genetic variability on clinical response to caffeine citrate in Chinese preterm infants.

METHODS

This single-center and retrospective study examined data from 112 preterm infants (< 35 weeks gestational age) between July 2017 and July 2018. Subjects were divided into apnoea-free (n = 48) and apnoeic (n = 64) groups, and their clinical outcomes were summarized. Liquid chromatography-tandem mass spectrometry was used to measure levels of caffeine and its primary metabolites. Eighty-eight single-nucleotide polymorphisms were chosen for genotyping by a MassARRAY system.

RESULTS

Preterm infants in the apnoea-free group were associated with a reduction in the incidence of bronchopulmonary dysplasia and a reduced requirement for patent ductus arteriosus ligation. No significant association was observed between plasma-trough-concentration-to-dose (C₀/D) ratio and birth weight, gestational age, or postnatal age in either group. Polymorphisms in CYP1A2 and aryl hydrocarbon receptor (AHR) genes did not affect plasma caffeine levels. Polymorphisms in adenosine receptor genes ADORA1 (rs10920568 and rs12744240), ADORA2A (rs34923252 and rs5996696), and ADORA3 (rs10776727 and rs2298191), especially in AHR (rs4410790) and adenosine deaminase (rs521704), play critical roles in the interindividual response to caffeine therapy.

CONCLUSIONS

Genetic polymorphisms in caffeine's target receptors, but not the exposure levels based on the standard dosing, were associated with variable responses to caffeine therapy in preterm neonates. Future studies are needed to uncover how these genetic variants affect responses to caffeine therapy in this patient population.

Early full enteral feeding for preterm or low birth weight infants

BACKGROUND

The introduction and advancement of enteral feeds for preterm or low birth weight infants is often delayed because of concerns that early full enteral feeding will not be well tolerated or may increase the risk of necrotising enterocolitis. Early full enteral feeding, however, might increase nutrient intake and growth rates; accelerate intestinal physiological, metabolic, and microbiomic postnatal transition; and reduce the risk of complications associated with intravascular devices for fluid administration.  OBJECTIVES: To determine how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth and adverse events such as necrotising enterocolitis, in preterm or low birth weight infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials; MEDLINE Ovid, Embase Ovid, Maternity & Infant Care Database Ovid, the Cumulative Index to Nursing and Allied Health Literature, and clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials to October 2020.

SELECTION CRITERIA

Randomised controlled trials that compared early full enteral feeding with delayed or progressive introduction of enteral feeds in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately assessed trial eligibility, evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RR), risk differences, and mean differences (MD) with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six trials. All were undertaken in the 2010s in neonatal care facilities in India. In total, 526 infants participated. Most were very preterm infants of birth weight between 1000 g and 1500 g. Trials were of good methodological quality, but a potential source of bias was that parents, clinicians, and investigators were not masked. The trials compared early full feeding (60 mL/kg to 80 mL/kg on day one after birth) with minimal enteral feeding (typically 20 mL/kg on day one) supplemented with intravenous fluids. Feed volumes were advanced daily as tolerated by 20 mL/kg to 30 mL/kg body weight to a target steady-state volume of 150 mL/kg to 180 mL/kg/day. All participating infants were fed preferentially with maternal expressed breast milk, with two trials supplementing insufficient volumes with donor breast milk and four supplementing with preterm formula.  Few data were available to assess growth parameters. One trial (64 participants) reported a slower rate of weight gain (median difference -3.0 g/kg/day), and another (180 participants) reported a faster rate of weight gain in the early full enteral feeding group (MD 1.2 g/kg/day). We did not meta-analyse these data (very low-certainty evidence). None of the trials reported rate of head circumference growth. One trial reported that the mean z-score for weight at hospital discharge was higher in the early full enteral feeding group (MD 0.24, 95% CI 0.06 to 0.42; low-certainty evidence). Meta-analyses showed no evidence of an effect on necrotising enterocolitis (RR 0.98, 95% CI 0.38 to 2.54; 6 trials, 522 participants; I² = 51%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Trials provided insufficient data to determine with any certainty how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth in preterm or low birth weight infants. We are uncertain whether early full enteral feeding affects the risk of necrotising enterocolitis because of the risk of bias in the trials (due to lack of masking), inconsistency, and imprecision.

Nesfatin-1 ameliorates oxidative bowel injury in rats with necrotizing enterocolitis: The role of the microbiota composition and claudin-3 expression

BACKGROUND AND PURPOSE

Ongoing high mortality due to necrotizing enterocolitis (NEC) necessitates the investigation of novel treatments to improve the outcome of the affected newborns. The aim was to elucidate the potential therapeutic impact of the nesfatin-1, a peptide with anti-inflammatory and anti-apoptotic effects in several inflammatory processes, on NEC-induced newborn rats.

MATERIALS AND METHODS

Sprague-Dawley pups were separated from their mothers, fed with a hyperosmolar formula and exposed to hypoxia, while control pups had no intervention. NEC-induced pups received saline or nesfatin-1 (0.2 μg/kg/day) for 3 days, while some nesfatin-1 treated pups were injected with capsaicin (50 μg/g) for the chemical ablation of afferent neurons. On the 4th day, clinical state and macroscopic gut assessments were made. In intestines, immunohistochemical staining of cycloxygenase-2 (COX-2), nuclear factor (NF)-κB-p65 (RelA), vascular endothelial growth factor (VEGF), claudin-3 and zonula occludens-1 (ZO-1) were performed, while gene expressions of COX-2, occludin, claudin-3, NF-κB-p65 (RelA) and VEGF were determined using q-PCR. In fecal samples, relative abundance of bacteria was quantified by q-PCR. Biochemical evaluation of oxidant/antioxidant parameters was performed in both intestinal and cerebral tissues.

RESULTS

Claudin-3 and ZO-1 immunoreactivity scores were significantly elevated in the nesfatin-1 treated control pups. Nesfatin-1 reduced NEC-induced high macroscopic and clinical scores, inhibited NF-κB-65 pathway and maintained the balance of oxidant/antioxidant systems. NEC increased the abundance of Proteobacteria with a concomitant reduction in Actinobacteria and Bacteroidetes, while nesfatin-1 treatment reversed these alterations. Modulatory effects of nesfatin-1 on microbiota and oxidative injury were partially reversed by capsaicin. Immunohistochemistry demonstrated that nesfatin-1 abolished NEC-induced reduction in claudin-3. Gene expressions of COX-2, NF-κB, occludin and claudin-3 were elevated in saline-treated NEC pups, while these up-regulated mRNA levels were not further altered in nesfatin-1-treated NEC pups.

CONCLUSION

Nesfatin-1 could be regarded as a potential preventive agent for the treatment of NEC.

Low serum albumin concentration predicts the need for surgical intervention in neonates with necrotizing enterocolitis

PURPOSE

To investigate whether serum albumin (SA) concentration can predict the need for surgical intervention in neonates with necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all cases with NEC Bell's stage 2 and 3 that were treated in a single center between 2009 and 2015. Data on patient demographics, clinical parameters, laboratory findings and surgical status were recorded. Receiver operating characteristics analysis was used to evaluate optimal cutoffs and predictive values.

RESULTS

Overall, 151 neonates with NEC were identified. Of these, 132 (87.4%) had confirmed NEC Bell's stage 2. The median gestational age was 28.4 (range, 23.1-39.0) weeks and 69 (52.3%) had a birth weight of ≤1000 g. Sixty-eight (51.5%) underwent surgery, showing a sustained reduction in SA over time with significantly lower median SA levels compared to 64 (48.5%) cases that responded well to medical treatment (18.3 ± 3.7 g/L vs. 26.0 ± 2.0 g/L; P < 0.001). SA concentration of ≤20 g/L on day 2 of NEC diagnosis was a significant predictor for surgery (OR 3.41; P = 0.019) with a positive predictive value of 71.4%.

CONCLUSIONS

An SA concentration of ≤20 g/L on day 2 of the NEC disease process is associated with a higher likelihood for surgical intervention in neonates with NEC Bell's stage 2. SA, in combination with other clinical parameters and serological markers, may be a useful predictive tool for surgery in NEC.

LEVEL OF EVIDENCE

II.

Mortality rate-dependent variations in antenatal corticosteroid-associated outcomes in very low birth weight infants with 23-34 weeks of gestation: A nationwide cohort study

Antenatal corticosteroid (ACS) administration has been known as one of the most effective treatment in perinatal medicine, but the beneficial effects of ACS may vary not only gestational age, but also the quality of perinatal and neonatal care of the institution. This nationwide cohort study of the Korean Neonatal Network (KNN) data was consisted of <1,500g infants born at 23–34 weeks at 67 KNN hospitals between 2013 and 2017. The 9,142 eligible infants were assigned into two groups–group 1 and 2 <50% and ≥50% mortality rate, respectively, for 23–24 weeks’ gestation–reflecting the quality of perinatal and neonatal care. Each group of infants were further stratified into 23–24, 25–26, 27–28, and 29–34 weeks of gestation age. Despite comparable ACS usage between group 1 (82%) and group 2 (81%), the benefits of ACS were only observed in group 1. In the multivariable analyses, infants of group 1 showed significant decrease in mortality and IVH at gestational age 23–24 weeks with ACS use, and the decrease was also seen in early-onset sepsis and respiratory distress syndrome at gestational age of 29–34 weeks while there were no significant decrease in group 2. In this study the overall data was congruent with the previous findings stating that ACS use decreases mortality and morbidity. These results indicate that the improved mortality of infants at 23–24 weeks’ gestation reflects the quality improvement of perinatal and neonatal intensive care, which is a prerequisite to the benefits of ACS.

Global incidence of Necrotizing Enterocolitis: a systematic review and Meta-analysis

BACKGROUND

Necrotizing Enterocolitis (NEC) is a major cause of morbidity and mortality in the Neonatal Intensive Care Unit (NICU), yet the global incidence of NEC has not been systematically evaluated. We conducted a systematic review and meta-analysis of cohort studies reporting the incidence of NEC in infants with Very Low Birth Weight (VLBW).

METHODS

The databases searched included PubMed, MEDLINE, the Cochrane Library, EMBASE and grey literature. Eligible studies were cohort or population-based studies of newborns including registry data reporting incidence of NEC. Incidence were pooled using Random Effect Models (REM), in the presence of substantial heterogeneity. Additional, bias adjusted Quality Effect Models (QEM) were used to get sensitivity estimates. Subgroup analysis and meta-regression were used to explore the sources of heterogeneity. Funnel plots as appropriate for ratio measures were used to assess publication bias.

RESULTS

A systematic and comprehensive search of databases identified 27 cohort studies reporting the incidence of NEC. The number of neonate included in these studies was 574,692. Of this 39,965 developed NEC. There were substantial heterogeneity between studies (I2 = 100%). The pooled estimate of NEC based on REM was 7.0% (95% CI: 6.0-8.0%). QEM based estimate (6.0%; 95% CI: 4.0-9.0%) were also similar. Funnel plots showed no evidence of publication bias. Although, NEC estimates are similar across various regions, some variation between high and low income countries were noted. Meta regression findings showed a statistically significant increase of NEC over time, quantified by the publication year.

CONCLUSION

Seven out of 100 of all VLBW infants in NICU are likely to develop NEC. However, there were considerable heterogeneity between studies. High quality studies assessing incidence of NEC along with associated risk factors are warranted.

Saccharomyces boulardii modulates necrotizing enterocolitis in neonatal mice by regulating the sirtuin 1/NF‑κB pathway and the intestinal microbiota

Exaggerated inflammatory response and gut microbial dysbiosis play a crucial role in necrotizing enterocolitis (NEC). The probiotic Saccharomyces boulardii (SB) is a yeast that has a beneficial effect on NEC; however, the association between its protective effects and the regulation of the inflammation-related sirtuin 1 (SIRT1)/nuclear factor-κB (NF-κB) signaling pathway and gut microbiota in NEC is unknown. In the present study, the NEC model was established by artificial feeding and lipopolysaccharide (LPS), hypoxia and hypothermia stimulation. Mice were divided into normal, control (artificial feeding), NEC and NEC + SB groups. Hematoxylin and eosin staining demonstrated that SB improved the pathological damage of the intestine caused by NEC in neonatal mice. Furthermore, downregulation of SIRT1 and upregulation of NF-κB expression were confirmed by immunofluorescence staining, western blotting and reverse transcription-quantitative PCR (RT-qPCR) in NEC mice. SB treatment concurrently inhibited the NEC roles on the SIRT1 and NF-κB pathway at both the protein and mRNA levels. Deletion of SIRT1 [SIRT1 knockout (KO)] in the intestine abolished all the effects of SB in NEC mice, including protection of pathological damage and inhibition of the SIRT1/NF-κB pathway activation. The abundance of gut microbial composition, as determined by RT-qPCR, was significantly decreased in the control group compared with the normal group. A further decrease in microbiota abundance was observed in the NEC group, and SB administration significantly improved the enrichment of gut microbiota in neonatal mice with NEC. As anticipated, the increased abundance of gut microbiota modulated by SB was markedly reduced in SIRT1KO NEC mice. The present study revealed that the protective role of SB on NEC was associated with the SIRT1/NF-κB pathway and gut microbiota regulation.

Human Milk Oligosaccharides Activate Epidermal Growth Factor Receptor and Protect Against Hypoxia-Induced Injuries in the Mouse Intestinal Epithelium and Caco2 Cells

BACKGROUND

Hypoxia-induced intestinal barrier injuries lead to necrotizing enterocolitis (NEC). Although NEC in preterm neonates is preventable by human milk oligosaccharides (HMOs), the underlying mechanism remains unknown.

OBJECTIVE

To reveal the role and mechanism of HMOs in protecting against hypoxia-induced injuries in intestinal epithelium of neonatal mice and cultured Caco2 cells.

METHODS

NEC was induced by hypoxia and cold stress. Seventy C57BL/C pups (7-d-old) were divided into 5 groups and fed maternal breast milk (BM), formula alone (FF), or the formula added with HMOs at 5 (LHMO), 10 (MHMO), or 20 mg/mL (HHMO) for 3 d. Ileal hypoxia inducible factor 1α (HIF1α) and cleaved Caspase 3 were determined, along with staining for Ki-67 protein to labeled proliferative cells. In vitro, adherent Caco2 cells (undifferentiated, passage 14) were treated with HMOs, galacto-oligosaccharides, fructo-oligosaccharides, or mixed oligosaccharides at 10 mg/mL for 1 d exposed to 1% O2. Cell proliferation and apoptosis, along with phosphorylated epidermal growth factor receptor (P-EGFR) and 38KD MAPK (P-P38), were assayed in differentiated or undifferentiated Caco2 cells.

RESULTS

Compared with the FF-fed mice, those fed MHMO and HHMO had 52% lower (P < 0.05) NEC scores, 60-80% greater (P < 0.05) KI67-positive cell numbers, and 56-71% decreases (P < 0.05) in ileal HIF1α and cleaved Caspase 3 (56-71%). Compared with those untreated, the HMO-treated Caco2 cells displayed 60% greater (P < 0.05) proliferative activity and 19% lower (P < 0.05) apoptotic cells after the hypoxia exposure. The HMO treatment led to 58% or 10-fold increases (P < 0.05) of P-EGFR and 48-89% decreases (P < 0.05) of P-P38 in either differentiated or undifferentiated Caco2 cells compared with the controls.

CONCLUSION

Supplementing HMOs at 10-20 mg/mL into the formula for neonatal mice or media for Caco2 cells conferred protection against the hypoxia-induced injuries. The protection in the Caco2 cells was associated with an activation of EGFR.

Early full enteral feeding for preterm or low birth weight infants

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

We aim to assess the benefits and harms of early full enteral nutrition versus progressive introduction of enteral feeds in preterm or low birth weight (LBW) infants.

Where data are available, we will undertake subgroup analyses of very preterm or very low birth weight (VLBW) infants (versus infants born after a longer gestation or with higher birth weight), infants who are 'small for gestational age' at birth (versus those deemed 'appropriate for gestation'), infants fed with human milk only (versus formula‐fed infants), and trials set in low‐ or middle‐income countries (versus high‐income countries).

Jungen sterben häufiger an nekrotisierender Enterokolitis

Hintergrund

In den letzten Jahren verringerte sich die frühgeburtliche Morbidität und Mortalität über Ländergrenzen hinweg deutlich. Allen Untersuchungen gemeinsam ist aber eine höhere Betroffenheit und Sterblichkeit von Jungen gegenüber Mädchen, insbesondere bei der nekrotisierenden Enterokolitis.

Fragestellung

Besteht in Deutschland auf Basis der amtlichen Krankenhausstatistik eine höhere Inzidenz oder Sterblichkeit von Jungen an nekrotisierender Enterokolitis?

Material und Methoden

Die Autoren werteten die Diagnosedaten der amtlichen Krankenhausstatistik für die Jahre 2000–2017 für die Hauptdiagnose P77 – nekrotisierende Enterokolitis –, getrennt nach Geschlechtern und Überleben, aus. Der Zusammenhang zwischen Geschlecht und Versterben resp. Erkrankungshäufigkeit wurde mittels einseitigem χ2-Test auf ein höheres Risiko für Jungen untersucht.

Ergebnisse

Zwischen 2000 und 2017 hatten 3119 Frühgeborene die Hauptdiagnose nekrotisierende Enterokolitis, davon 1769 Jungen (0,27 ‰ der männlichen Lebendgeburten) und 1350 Mädchen (0,22 ‰ der weiblichen Lebendgeburten). Jungen haben ein höheres Risiko, an nekrotisierender Enterokolitis zu erkranken (relatives Risiko 1,24, 95 %-Konfidenzintervall: 1,17–∞, p < 0,001) und zu versterben (relatives Risiko 1,25, 95 %-Konfidenzintervall: 1,02–∞, p = 0,036).

Diskussion

Jungen erkranken und sterben häufiger an nekrotisierender Enterokolitis als Mädchen. Allerdings erfasst die amtliche Statistik nicht die leichteren Fälle einer nekrotisierenden Enterokolitis, da nur die Hauptdiagnose erfasst wird. Überdies ermöglicht die amtliche Statistik keine Adjustierung für verzerrende Faktoren. Die sekundäre Datennutzung der Qualitätssicherungsdaten der Neonatalerhebung könnte eine detailliertere Untersuchung dieser Fragestellung ermöglichen.

Mode of delivery and necrotizing enterocolitis in very preterm very-low-birth-weight infants

Objective: To investigate the association between delivery mode and necrotizing enterocolitis (NEC) in very preterm (24-31 weeks' gestational age (GA)) very-low-birth-weight (VLBW) (≤1500 g) infants.Design: Population-based observational study using univariate and multivariable logistic regression analyses.Setting: The Israel National VLBW infant database 1995-2015.Patients: 20,223 VLBW infants, 11,832 singletons and 8391 multiples.Main outcome measures: The association of NEC occurrence to delivery by cesarean section (CS) in singletons and multiples VLBW very preterm infants.Results: NEC occurred in 7.6% of singletons and 6.4% of multiples. 71.5% were delivered by CS (64.7% of singletons, 80.9% of multiples). CS delivery was not significantly associated with NEC stages 2-3 in singletons; but multiple births CS were associated with significantly higher odds for NEC (OR 1.31, 95% CI 1.01-1.69). Odds for NEC were greater with lower GA, small for GA (SGA) and patent ductus arteriosus (PDA) in both singletons and multiples, and lower in multiples with antenatal corticosteroids.Conclusions: We demonstrated association between deliveries by CS and increased risk for NEC only in multiple pregnancies.

Formula feeding and immature gut microcirculation promote intestinal hypoxia, leading to necrotizing enterocolitis

Major risk factors for necrotizing enterocolitis (NEC) are formula feeding and prematurity; however, their pathogenic mechanisms are unknown. Here, we found that insufficient arginine/nitric oxide synthesis limits blood flow in the intestinal microvasculature, leading to hypoxia, mucosal damage and NEC in the premature intestine after formula feeding. Formula feeding led to increased intestinal hypoxia in pups at postnatal day (P)1 and P5, but not in more mature pups at P9. Accordingly, blood flow in the intestinal microvasculature increased after formula feeding in P9 pups only. mRNA profiling revealed that regulators of arginine/nitric oxide synthesis are at higher levels in endothelial cells of the intestine in P9 than in P1 pups. Importantly, arginine supplementation increased intestinal microvasculature blood flow and prevented NEC, whereas an arginine antagonist exacerbated NEC. Our results suggest that balancing intestinal oxygen demand and supply in the premature intestine by modulating arginine/nitric oxide could be used to prevent NEC.This article has an associated First Person interview with the first author of the paper.

Necrotizing enterocolitis: It's not all in the gut

Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.

Impact statement

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.