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Imam ZO, Nabwera HM, Tongo OO, Andang’o PEA, Abdulkadir I, Ezeaka CV, Ezenwa BN, Fajolu IB, Mwangome MK, Umoru DD, Akindolire AE, Otieno W, Olwala M, Nalwa GM, Talbert AW, Abubakar I, Embleton ND, Allen SJ. Time to full enteral feeds in hospitalised preterm and very low birth weight infants in Nigeria and Kenya. PLoS One 2024; 19:e0277847. [PMID: 38457475 PMCID: PMC10923414 DOI: 10.1371/journal.pone.0277847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/18/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Preterm (born < 37 weeks' gestation) and very low birthweight (VLBW; <1.5kg) infants are at the greatest risk of morbidity and mortality within the first 28 days of life. Establishing full enteral feeds is a vital aspect of their clinical care. Evidence predominantly from high income countries shows that early and rapid advancement of feeds is safe and reduces length of hospital stay and adverse health outcomes. However, there are limited data on feeding practices and factors that influence the attainment of full enteral feeds among these vulnerable infants in sub-Saharan Africa. AIM To identify factors that influence the time to full enteral feeds, defined as tolerance of 120ml/kg/day, in hospitalised preterm and VLBW infants in neonatal units in two sub-Saharan African countries. METHODS Demographic and clinical variables were collected for newborns admitted to 7 neonatal units in Nigeria and Kenya over 6-months. Multiple linear regression analysis was conducted to identify factors independently associated with time to full enteral feeds. RESULTS Of the 2280 newborn infants admitted, 484 were preterm and VLBW. Overall, 222/484 (45.8%) infants died with over half of the deaths (136/222; 61.7%) occurring before the first feed. The median (inter-quartile range) time to first feed was 46 (27, 72) hours of life and time to full enteral feeds (tFEF) was 8 (4.5,12) days with marked variation between neonatal units. Independent predictors of tFEF were time to first feed (unstandardised coefficient B 1.69; 95% CI 1.11 to 2.26; p value <0.001), gestational age (1.77; 0.72 to 2.81; <0.001), the occurrence of respiratory distress (-1.89; -3.50 to -0.79; <0.002) and necrotising enterocolitis (4.31; 1.00 to 7.62; <0.011). CONCLUSION The use of standardised feeding guidelines may decrease variations in clinical practice, shorten tFEF and thereby improve preterm and VLBW outcomes.
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Affiliation(s)
- Zainab O. Imam
- Massey Street Children’s Hospital, Lagos Island, Lagos, Nigeria
| | - Helen M. Nabwera
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Alder Hey Children’s Hospital NHS Trust, Liverpool, United Kingdom
| | - Olukemi O. Tongo
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Isa Abdulkadir
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria
| | - Chinyere V. Ezeaka
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Beatrice N. Ezenwa
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Iretiola B. Fajolu
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Martha K. Mwangome
- Department of Clinical Research, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Dominic D. Umoru
- Department of Paediatrics, Maitama District Hospital, Maitama, Abuja, Nigeria
| | | | - Walter Otieno
- Maseno University, Maseno, Kenya
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Macrine Olwala
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Grace M. Nalwa
- Maseno University, Maseno, Kenya
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Alison W. Talbert
- Department of Clinical Research, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ismaela Abubakar
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas D. Embleton
- Department of Paediatrics, Newcastle University, Newcastle upon Tyne, United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen J. Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Clyman RI, Hills NK. Prophylactic indomethacin, antenatal betamethasone, and the risk of intestinal perforation in infants <28 weeks' gestation. J Perinatol 2023; 43:1252-1261. [PMID: 36973384 DOI: 10.1038/s41372-023-01653-0] [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: 01/27/2023] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To determine if intestinal perforations before 14 days (either spontaneous (SIP) or necrotizing enterocolitis-induced) are increased when infants who received antenatal betamethasone shortly before birth are treated with prophylactic indomethacin (PINDO). STUDY DESIGN Observational study of 475 infants <28 week's gestation assigned to either a PINDO-protocol (n = 231) or expectant management protocol (n = 244) during consecutive protocol epochs. RESULTS Intestinal perforations before 14 days occurred in 33/475 (7%). In unadjusted and adjusted models, we found no associations between PINDO-protocol and intestinal perforations. PINDO-protocol did not increase intestinal perforations or SIP-alone even when given to infants who received betamethasone <7 or <2 days before delivery. 213/231 (92%) PINDO-protocol infants actually received indomethacin. The results were unchanged when examined just in those who received indomethacin. CONCLUSION In our study, early intestinal perforations and SIP-alone were not increased when PINDO was used by protocol in infants who received antenatal betamethasone shortly before birth.
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- Department of Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA.
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Berken JA, Chang J. Neurologic consequences of neonatal necrotizing enterocolitis. Dev Neurosci 2022; 44:295-308. [PMID: 35697005 DOI: 10.1159/000525378] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/24/2022] [Indexed: 11/19/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease of the premature infant with high mortality and morbidity. Children who survive NEC have been shown to demonstrate neurodevelopmental delay, with significantly worse outcomes than from prematurity alone. The pathways leading to NEC-associated neurological impairments remain unclear, limiting the development of preventative and protective strategies. This review aims to summarize the existing clinical and experimental studies related to NEC-associated brain injury. We describe the current epidemiology of NEC, reported long-term neurodevelopmental outcomes among survivors, and proposed pathogenesis of brain injury in NEC. Highlighted are the potential connections between hypoxia-ischemia, nutrition, infection, gut inflammation, and the developing brain in NEC.
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Affiliation(s)
- Jonathan A Berken
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jill Chang
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA,
- Division of Neonatal-Perinatal Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA,
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Abstract
Necrotizing enterocolitis (NEC) is considered to be one of the most devastating intestinal diseases seen in neonatal intensive care. Measures to treat NEC are often too late, and we need effective preventative measures to alleviate the burden of this disease. The purpose of this review is to summarize currently used measures, and those showing future promise for prevention.
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Affiliation(s)
- Josef Neu
- University of Florida, Gainesville, FL, USA.
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Enteral Feeding and Necrotizing Enterocolitis: Does Time of First Feeds and Rate of Advancement Matter? J Pediatr Gastroenterol Nutr 2021; 72:763-768. [PMID: 33587409 DOI: 10.1097/mpg.0000000000003069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
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A role for neonatal bacteremia in deaths due to intestinal perforation: spontaneous intestinal perforation compared with perforated necrotizing enterocolitis. J Perinatol 2020; 40:1662-1670. [PMID: 32433511 PMCID: PMC7578088 DOI: 10.1038/s41372-020-0691-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the relationship between intestinal perforations (caused by either spontaneous perforation (SIP) or necrotizing enterocolitis (NEC)) and the outcome "death due to intestinal perforation". METHODS Multivariable logistic regression analyses were used to compare infants <28 weeks' gestation with SIP (n = 32) and perforated-NEC (n = 45) for the outcome perforation-related death. RESULTS In univariate analyses the incidence of death due to perforation was higher among infants with perforated-NEC (36%) than infants with SIP (13%). However, infants with perforated-NEC were more likely to be older than 10 days and have bacteremia/fungemia with non-coagulase-negative staphylococci (non-CONS) organisms than infants with SIP. After adjusting for confounding the only variable that was significantly associated with mortality due to perforation was the presence of non-CONS bacteremia/fungemia at the onset of perforation. CONCLUSIONS The apparent association between death and perforated-NEC could be explained by the higher incidence of non-CONS bacteremia/fungemia among infants with perforated-NEC.
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Wang FS, Yu ML, Li WZ, Hong K, Xu CB, Wang GH. Intestinal tract and parenteral multi-organ sequential pathological injury caused by necrotizing enterocolitis. BMC Pediatr 2020; 20:418. [PMID: 32878600 PMCID: PMC7465432 DOI: 10.1186/s12887-020-02304-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To explore the relationship between the pathological changes of the colon, terminal ileum, lung, liver and kidney, and the changes of Bax, PCNA and PAF in a rat model of NEC. METHODS One hundred and forty neonatal SD rats were randomly divided into NEC group and control group (70 in each group). NEC group was given hypoxia, cold stimulation and artificial feeding twice a day for 3 consecutive days. The control group was only fed normally. After modeling, From the 1st day to the 7th day, 10 rats were sampled in each group for pathological examination of colon, terminal ileum, lung, liver and kidney tissue. The levels of Bax, PCNA and PAF were investigated by immunohistochemistry. RESULTS Compared with the normal group, in the NEC group, on the 1st day, the colon, terminal ileum, lung, liver and kidney showed inflammatory damage. On the 5th day, the inflammatory injury was reduced. The inflammation disappeared on the 7th day. There were differences in the time of apoptosis in the intestine. In the intestine, the proliferation of PCNA was weak at first and then strong. Bax in liver and kidney showed marked apoptosis and apoptosis time increased in the lung. The expression of PCNA increased in lung, liver and kidney, and the expression of PAF increased in lung and liver. CONCLUSIONS NEC can lead to secondary injury of different degrees in colon, terminal ileum, lung, liver and kidney, and the degree and time of injury and repair were different. In general, organ repair played a leading role on the 4th day after modeling.
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Affiliation(s)
- Fu-Sheng Wang
- Department of Pediatric Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Meng-Lu Yu
- Department of Pediatric Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Wei-Zhong Li
- Department of Neonatal, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Kai Hong
- Department of Clinical Laboratory, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Chen-Bin Xu
- Department of Pediatric Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Guang-Huan Wang
- Department of Pediatric Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China.
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Burrin D, Sangild PT, Stoll B, Thymann T, Buddington R, Marini J, Olutoye O, Shulman RJ. Translational Advances in Pediatric Nutrition and Gastroenterology: New Insights from Pig Models. Annu Rev Anim Biosci 2020; 8:321-354. [PMID: 32069436 DOI: 10.1146/annurev-animal-020518-115142] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pigs are increasingly important animals for modeling human pediatric nutrition and gastroenterology and complementing mechanistic studies in rodents. The comparative advantages in size and physiology of the neonatal pig have led to new translational and clinically relevant models of important diseases of the gastrointestinal tract and liver in premature infants. Studies in pigs have established the essential roles of prematurity, microbial colonization, and enteral nutrition in the pathogenesis of necrotizing enterocolitis. Studies in neonatal pigs have demonstrated the intestinal trophic effects of akey gut hormone, glucagon-like peptide 2 (GLP-2), and its role in the intestinal adaptation process and efficacy in the treatment of short bowel syndrome. Further, pigs have been instrumental in elucidating the physiology of parenteral nutrition-associated liver disease and the means by which phytosterols, fibroblast growth factor 19, and a new generation of lipid emulsions may modify disease. The premature pig will continue to be a valuable model in the development of optimal infant diets (donor human milk, colostrum), specific milk bioactives (arginine, growth factors), gut microbiota modifiers (pre-, pro-, and antibiotics), pharmaceutical drugs (GLP-2 analogs, FXR agonists), and novel diagnostic tools (near-infrared spectroscopy) to prevent and treat these pediatric diseases.
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Affiliation(s)
- Douglas Burrin
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Per Torp Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Barbara Stoll
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Randal Buddington
- College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - Juan Marini
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA; .,Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Oluyinka Olutoye
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Robert J Shulman
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
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Mcelroy SJ. Another Brick in the Wall: Discovering the Role of Necroptosis in Neonatal Necrotizing Enterocolitis. Cell Mol Gastroenterol Hepatol 2020; 9:549-550. [PMID: 31904352 PMCID: PMC7078441 DOI: 10.1016/j.jcmgh.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/10/2022]
Affiliation(s)
- Steven J. Mcelroy
- Correspondence Address correspondence to: Steven J. McElroy, MD, Stead Family Department of Pediatrics and Department of Microbiology and Immunology, University of Iowa, 1270A CBRB, 285 Newton Rd, Iowa City, Iowa 52242.
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Necrotizing Enterocolitis: Using Regulatory Science and Drug Development to Improve Outcomes. J Pediatr 2019; 212:208-215.e1. [PMID: 31235383 DOI: 10.1016/j.jpeds.2019.05.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/02/2019] [Accepted: 05/13/2019] [Indexed: 01/24/2023]
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Franchi T, Eaton S, De Coppi P, Giuliani S. The emerging role of immunothrombosis in paediatric conditions. Pediatr Res 2019; 86:19-27. [PMID: 30808021 DOI: 10.1038/s41390-019-0343-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/15/2019] [Accepted: 02/01/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immunothrombosis is a physiological process based on the release of neutrophil extracellular traps (NETs) to immobilise, contain and kill bacteria. This is an innate immune response in which the local activation of blood coagulation exerts the critical protective function during microbial infection. In recent years, there has been much interest in the adult literature about the key role of immunothrombosis in pathologic states including thrombosis, cancer, sepsis and trauma. Currently, little research has been done into its role in paediatric conditions. METHODS We conducted a literature search of the National Library of Medicine (MEDLINE/PubMed) from the years 2000 to May 2018 and qualitatively identified 24 relevant papers. References of articles included for full-text review were checked for relevant publications. RESULTS Our aim is to summarise the most relevant evidences regarding an excessive production or defective removal of NETs in paediatric conditions. In particular, we have divided the role of immunothrombosis into acute (sepsis, necrotising enterocolitis, otitis media, neonatal arterial ischaemic stroke, haemolytic anaemic diseases) and chronic (systemic lupus erythematous, type 1 diabetes mellitus, respiratory diseases, graft-versus-host disease) conditions to find important similarities in their pathophysiology. CONCLUSION The field of immunothrombosis in paediatric conditions is still in its infancy. We have presented multiple pathways of NET-induced disease together with possible areas of future research and treatments.
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Affiliation(s)
- Thomas Franchi
- The Medical School, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, University College London-Institute of Child Health, London, UK
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine Section, University College London-Institute of Child Health, London, UK.,Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, UK
| | - Stefano Giuliani
- Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, UK.
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Teixeira LC, Fujiki RTM, Souza CVCPD, Souza CMD, Mismetti MM, Artigiane-Neto R, Montero EFDS, Martins JL. Oxidative stress assessment in intestine of newborn rats submitted to hypoxia and reoxygenation with tadalafil. Acta Cir Bras 2019; 34:e201900407. [PMID: 31038585 PMCID: PMC6583938 DOI: 10.1590/s0102-865020190040000007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/25/2019] [Indexed: 11/22/2022] Open
Abstract
Purpose: To evaluate the functional and structural response of tadalafil effects in the intestinal mucosa, using an experimental model of hypoxia and reoxygenation injury in rats. Methods: The animals were divided into 4 groups: CTL, H/R, H/R+Td and M+Td. The newborn rats allocated in groups H/R, H/R+Td and M+Td were submitted twice a day, to a gas chamber with CO2 at 100% for 10 minutes and afterward reoxygenation with O2 at 98% for 10 minutes, in the three first days of life. Tadalafil dose was given to newborn of group H/R+Td and to the pregnant rat of group M+Td. Histological analysis was made with hematoxylin-eosin technique and oxidative stress through nitrite and nitrate levels and lipid peroxidation. Results: The histological analysis showed a reduction of mucosa alterations in the groups that received tadalafil. In the oxidative stress evaluation, occurred an increase of NO levels and less lipidic peroxidation in the ileum segments that received tadalafil. Conclusion: Tadalafil provides tissue protection when administered independently to both, pregnant or newborns.
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Affiliation(s)
- Luciana Cristina Teixeira
- Fellow Master degree, Postgraduate Program in Interdisciplinary Surgical Science, Universidade Federal de São Paulo (UNIFESP), Brazil. Technical procedures; acquisition, analysis and interpretation of data; manuscript preparation
| | - Renato Toshio Murashita Fujiki
- Graduate student, UNIFESP, Sao Paulo-SP, Brazil. Technical procedures; acquisition, analysis and interpretation of data; manuscript preparation
| | | | - Camila Mendes de Souza
- Graduate student, UNIFESP, Sao Paulo-SP, Brazil. Technical procedures; acquisition, analysis and interpretation of data; manuscript preparation
| | - Maysa Moreira Mismetti
- Graduate student, Faculdade de Medicina Santa Marcelina, Sao Paulo-SP, Brazil. Technical procedures; acquisition, analysis and interpretation of data; manuscript preparation
| | - Ricardo Artigiane-Neto
- Associate Professor, Head, Department of Pathology, UNIFESP, Sao Paulo-SP, Brazil. Histopathological examinations, critical revision, final approval
| | - Edna Frasson de Souza Montero
- Associate Professor, Surgical Gastroenterology Division, Department of Surgery, UNIFESP, Sao Paulo-SP, Brazil. Scientific and intellectual content of the study, critical revision, final approval
| | - José Luiz Martins
- Full Professor, Pediatric Surgery Division, UNIFESP, Sao Paulo-SP, Brazil. Scientific, intellectual, conception and design of the study; critical revision; final approval
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Ng PC, Chan KYY, Yuen TP, Sit T, Lam HS, Leung KT, Wong RPO, Chan LCN, Pang YLI, Cheung HM, Chu WCW, Li K. Plasma miR-1290 Is a Novel and Specific Biomarker for Early Diagnosis of Necrotizing Enterocolitis-Biomarker Discovery with Prospective Cohort Evaluation. J Pediatr 2019; 205:83-90.e10. [PMID: 30529132 DOI: 10.1016/j.jpeds.2018.09.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/31/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To discover specific circulating microRNA (miRNA) biomarkers for the early differentiation of necrotizing enterocolitis (NEC) from neonatal sepsis and inflammatory conditions. STUDY DESIGN The study comprised 3 distinct phases: differential microarray analysis to compare plasma miRNA expression profiles of NEC vs sepsis and non-NEC/nonsepsis cases, a case-control study to quantify dysregulated miRNAs as potential specific biomarkers of NEC, and a prospective cohort study to assess the diagnostic usefulness of the best miRNA biomarker(s). RESULTS A distinct miRNA expression profile was observed in the NEC compared with the sepsis and non-NEC/nonsepsis groups. miR-1290, miR-1246, and miR-375 were discovered to be specific biomarkers of NEC in the case-control study. In the cohort study (n = 301), plasma miR-1290 (day 0; >220 copies/µL) provided the greatest diagnostic usefulness for identifying both mild medical and severe surgical NEC cases. Of 20 infants with miR-1290 >650 copies/µL, 15 were diagnosed with NEC. Incorporating C-reactive protein (day 1; >15.8 mg/L) for cases with intermediate levels (220-650 copies/µL) in a 2-stage algorithm further optimized the diagnostic profile with a sensitivity of 0.83, a specificity of 0.96, a positive predictive value of 0.75, and a negative predictive value of 0.98. Importantly, 7 of 36 infants with NEC (19.4%) could be diagnosed 7.8-32.2 hours earlier (median, 13.3 hours) using miR-1290. CONCLUSIONS Plasma miR-1290 is a novel and specific biomarker that can effectively differentiate NEC cases from neonatal sepsis. miR-1290 facilitates neonatologists to confidently and timely reach a decision for early transfer of sick infants with NEC from community-based hospitals to tertiary surgical centers.
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Affiliation(s)
- Pak Cheung Ng
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
| | - Kathy Yuen Yee Chan
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Terence Ping Yuen
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Tony Sit
- Department of Statistics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Hugh Simon Lam
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Kam Tong Leung
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Raymond Pui On Wong
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Lawrence Chi Ngong Chan
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Yennie Lap Ian Pang
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Hon Ming Cheung
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Winnie Chiu Wing Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Karen Li
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Necrotizing enterocolitis comes in different forms: Historical perspectives and defining the disease. Semin Fetal Neonatal Med 2018; 23:370-373. [PMID: 30100524 DOI: 10.1016/j.siny.2018.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The specific cause of what is commonly referred to as necrotizing enterocolitis (NEC) disease has been elusive largely because it is becoming clear that this entity represents more than one disease with multifactorial pathogenic mechanisms. Furthermore, finding clear and consistent diagnostic biomarkers will be difficult until the different subsets of what we are calling this disease are better delineated. In this introductory chapter, we discuss different disease entities that are frequently termed "NEC" in the newborn infant. We hope this will set the stage for more focused research and development of preventative measures for at least the most common forms of this disease.
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Nair J, Longendyke R, Lakshminrusimha S. Necrotizing Enterocolitis in Moderate Preterm Infants. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4126245. [PMID: 30406135 PMCID: PMC6199891 DOI: 10.1155/2018/4126245] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/18/2018] [Indexed: 11/21/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating morbidity usually seen in preterm infants, with extremely preterm neonates (EPT ≤28 weeks) considered at highest risk. Moderately preterm infants (MPT 28-34 weeks) constitute a large percentage of NICU admissions. In our retrospective data analysis of NEC in a single regional perinatal center, NEC was observed in 10% of extremely EPT and 7% of MPT, but only 0.7% of late-preterm/term admissions. There was an inverse relationship between postnatal age at onset of NEC and gestational age at birth. Among MPT infants with NEC, maternal hypertensive disorders (29%) and small for gestational age (SGA-15%) were more common than in EPT infants (11.6 and 4.6%, resp.). Congenital gastrointestinal anomalies were common among late preterm/term infants with NEC. SGA MPT infants born to mothers with hypertensive disorders are particularly at risk and should be closely monitored for signs of NEC. Identifying risk factors specific to each gestational age may help clinicians to tailor interventions to prevent NEC.
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Affiliation(s)
- Jayasree Nair
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
| | - Rachel Longendyke
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
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Robinson JL, Smith VA, Stoll B, Agarwal U, Premkumar MH, Lau P, Cruz SM, Manjarin R, Olutoye O, Burrin DG, Marini JC. Prematurity reduces citrulline-arginine-nitric oxide production and precedes the onset of necrotizing enterocolitis in piglets. Am J Physiol Gastrointest Liver Physiol 2018; 315:G638-G649. [PMID: 30048597 PMCID: PMC6415715 DOI: 10.1152/ajpgi.00198.2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Necrotizing enterocolitis (NEC) is associated with low plasma arginine and vascular dysfunction. It is not clear whether low intestinal citrulline production, the precursor for arginine synthesis, occurs before and thus predisposes to NEC or if it results from tissue damage. This study was designed to test the hypothesis that whole body rates of citrulline, arginine, and nitric oxide synthesis are low in premature pigs and that they precede NEC. Piglets delivered by cesarean section at 103 days [preterm (PT)], 110 days [near-term (NT)], or 114 days [full-term (FT)] of gestation were given total parenteral nutrition and after 2 days orogastrically fed infant formula for 42 h to induce NEC. Citrulline and arginine fluxes were determined before and during the feeding protocol. Gross macroscopic and histological NEC scores and plasma fatty acid binding protein (iFABP) concentration were determined as indicators of NEC. Intestinal gene expression for enzymes of the arginine pathway were quantitated. A lower ( P < 0.05) survival rate was observed for PT (8/27) than for NT (9/9) and FT pigs (11/11). PT pigs had higher macroscopic gross ( P < 0.05) and histological NEC ( P < 0.05) scores and iFABP concentration ( P < 0.05) than pigs of more advanced gestational age. PT pigs had lower citrulline production and arginine fluxes ( P < 0.05) throughout and a reduced gene expression in genes of the citrulline-arginine pathway. In summary, intestinal enzyme expression and whole body citrulline and arginine fluxes were reduced in PT pigs compared with animals of more advance gestational age and preceded the development of NEC. NEW & NOTEWORTHY Arginine supplementation prevents necrotizing enterocolitis (NEC), the most common gastrointestinal emergency of prematurity. Citrulline (precursor for arginine) production is reduced during NEC, and this is believed to be a consequence of intestinal damage. In a swine model of NEC, we show that intestinal gene expression of the enzymes for citrulline production and whole body citrulline and arginine fluxes are reduced and precede the onset of NEC in premature pigs. Reduced citrulline production during prematurity may be a predisposition to NEC.
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Affiliation(s)
- Jason L. Robinson
- 1United States Department of Agriculture, Agricultural Research Service, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Victoria A. Smith
- 2Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Barbara Stoll
- 1United States Department of Agriculture, Agricultural Research Service, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Umang Agarwal
- 1United States Department of Agriculture, Agricultural Research Service, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Muralidhar H. Premkumar
- 3Division of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Patricio Lau
- 4Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Stephanie M. Cruz
- 4Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Manjarin
- 2Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Oluyinka Olutoye
- 4Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Douglas G. Burrin
- 1United States Department of Agriculture, Agricultural Research Service, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Juan C. Marini
- 1United States Department of Agriculture, Agricultural Research Service, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas,5Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Abstract
Necrotizing enterocolitis is a serious complication of prematurity that is associated with an increased risk for adverse neurodevelopmental outcome secondary to a complex relationship between various morbidities that increase the risk for central nervous system injury. Affected infants are exposed to a variety of circulating cytokines known to be associated with white matter injury. These infants also have an increased risk of secondary blood stream infections and nutritional compromise.
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Affiliation(s)
- Ira Adams-Chapman
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine, Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30303, USA.
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18
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The Free Radical Diseases of Prematurity: From Cellular Mechanisms to Bedside. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:7483062. [PMID: 30140369 PMCID: PMC6081521 DOI: 10.1155/2018/7483062] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/28/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
During the perinatal period, free radicals (FRs) are involved in several physiological roles such as the cellular responses to noxia, the defense against infectious agents, the regulation of cellular signaling function, and the induction of a mitogenic response. However, the overproduction of FRs and the insufficiency of an antioxidant mechanism result in oxidative stress (OS) which represents a deleterious process and an important mediator of damage to the placenta and the developing fetus. After birth, OS can be magnified by other predisposing conditions such as hypoxia, hyperoxia, ischemia, hypoxia ischemia-reperfusion, inflammation, and high levels of nonprotein-bound iron. Newborns are particularly susceptible to OS and oxidative damage due to the increased generation of FRs and the lack of adequate antioxidant protection. This impairment of the oxidative balance has been thought to be the common factor of the so-called “free radical related diseases of prematurity,” including retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, kidney damage, and oxidative hemolysis. In this review, we provide an update focused on the factors influencing these diseases refining the knowledge about the role of OS in their pathogenesis and the current evidences of such relationship. Mechanisms governing FR formation and subsequent OS may represent targets for counteracting tissue damage.
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Gross Margolis K, Vittorio J, Talavera M, Gluck K, Li Z, Iuga A, Stevanovic K, Saurman V, Israelyan N, Welch MG, Gershon MD. Enteric serotonin and oxytocin: endogenous regulation of severity in a murine model of necrotizing enterocolitis. Am J Physiol Gastrointest Liver Physiol 2017; 313:G386-G398. [PMID: 28774871 PMCID: PMC5792212 DOI: 10.1152/ajpgi.00215.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 01/31/2023]
Abstract
Necrotizing enterocolitis (NEC), a gastrointestinal inflammatory disease of unknown etiology that may also affect the liver, causes a great deal of morbidity and mortality in premature infants. We tested the hypothesis that signaling molecules, which are endogenous to the bowel, regulate the severity of intestinal and hepatic damage in an established murine NEC model. Specifically, we postulated that mucosal serotonin (5-HT), which is proinflammatory, would exacerbate experimental NEC and that oxytocin (OT), which is present in enteric neurons and is anti-inflammatory, would oppose it. Genetic deletion of the 5-HT transporter (SERT), which increases and prolongs effects of 5-HT, was found to increase the severity of systemic manifestations, intestinal inflammation, and associated hepatotoxicity of experimental NEC. In contrast, genetic deletion of tryptophan hydroxylase 1 (TPH1), which is responsible for 5-HT biosynthesis in enterochromaffin (EC) cells of the intestinal mucosa, and TPH inhibition with LP-920540 both decrease the severity of experimental NEC in the small intestine and liver. These observations suggest that 5-HT from EC cells helps to drive the inflammatory damage to the gut and liver that occurs in the murine NEC model. Administration of OT decreased, while the OT receptor antagonist atosiban exacerbated, the intestinal inflammation of experimental NEC. Data from the current investigation are consistent with the tested hypotheses-that the enteric signaling molecules, 5-HT (positively) and OT (negatively) regulate severity of inflammation in a mouse model of NEC. Moreover, we suggest that mucosally restricted inhibition of 5-HT biosynthesis and/or administration of OT may be useful in the treatment of NEC.NEW & NOTEWORTHY Serotonin (5-HT) and oxytocin reciprocally regulate the severity of intestinal inflammation and hepatotoxicity in a murine model of necrotizing enterocolitis (NEC). Selective depletion of mucosal 5-HT through genetic deletion or inhibition of tryptophan hydroxylase-1 ameliorates, while deletion of the 5-HT uptake transporter, which increases 5-HT availability, exacerbates the severity of NEC. In contrast, oxytocin reduces, while the oxytocin receptor antagonist atosiban enhances, NEC severity. Peripheral tryptophan hydroxylase inhibition may be useful in treatment of NEC.
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Affiliation(s)
- Kara Gross Margolis
- Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York; .,Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Jennifer Vittorio
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Maria Talavera
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Karen Gluck
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Zhishan Li
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Alina Iuga
- 2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Korey Stevanovic
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Virginia Saurman
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Narek Israelyan
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
| | - Martha G. Welch
- 1Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York; ,2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and ,3Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - Michael D. Gershon
- 2Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; and
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Abstract
Necrotizing enterocolitis (NEC) is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Due to its multifactorial nature, there has been much uncertainty in identifying clear strategies for prevention of NEC. Despite these obstacles, the incidence of NEC has gradually been decreasing over the past 10 years, in part due to quality improvement (QI) initiatives to prevent NEC. Current QI strategies primarily target the various predisposing conditions. This article reviews the evidence on which QI interventions to prevent NEC have been based and provides examples of successful QI interventions.
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