Pathogenesis of NEC: Impact of an altered intestinal microbiome

Identification of near-infrared characteristic bands of small bowel necrosis based on cellwise detection algorithm

The near-infrared spectroscopy is often used to distinguish small bowel necrosis due to necrotizing enterocolitis (NEC). The characteristic bands of small bowel necrosis, as an important basis for evaluating the confidence of the differentiation results, are challenging to identify quickly. In this study, we proposed to identify characteristic bands of lesion samples based on hyperspectral imaging (HSI) and cellwise outlier detection. Rabbits were used as an animal model to simulate the clinical symptoms of NEC. The rabbits were detected at intervals of 10, 30, 60, and 90 min. The characteristic bands were identified within the same rabbit, between different rabbits and at different times. The result showed the bands near 763 nm, corresponding to the absorption peak of deoxyhemoglobin, were the characteristic bands separating samples with NEC. The identification result was plausible because hypoxia was the main cause of NEC. The method was easy to perform.

[Predictive value of hemoglobin decrease for necrotizing enterocolitis in preterm infants with late-onset sepsis]

OBJECTIVES

To study the predictive value of hemoglobin (Hb) decrease for the occurrence of necrotizing enterocolitis (NEC) in preterm infants with late-onset sepsis (LOS) .

METHODS

Clinical data of 93 LOS preterm infants were collected for retrospective analysis, among which 16 infants developed NEC while 77 infants did not. Based on the decrease in Hb levels from the most recent Hb measurement before LOS occurrence to the initial Hb levels during LOS, the infants were divided into three groups: no Hb decrease (n=15), mild Hb decrease (Hb decrease <15 g/L; n=35), and severe Hb decrease (Hb decrease ≥15 g/L; n=43). Multivariate logistic regression analysis was conducted to explore the predictive factors for NEC secondary to LOS, and the value of Hb decrease in predicting NEC secondary to LOS was evaluated through receiver operating characteristic curve analysis.

RESULTS

The incidence of NEC in the severe Hb decrease group, mild Hb decrease group, and no Hb decrease group were 26%, 14%, and 0% (P<0.05), respectively. Multivariate logistic regression analysis revealed that a larger Hb decrease was an independent predictive factor for NEC in LOS preterm infants (OR=1.141, 95%CI: 1.061-1.277, P<0.001). Receiver operating characteristic curve analysis showed that the area under the curve for predicting NEC in preterm infants with LOS using Hb decrease (with a cut-off value of 20 g/L) was 0.803, with sensitivity and specificity of 0.69 and 0.78, respectively.

CONCLUSIONS

Hb decrease can serve as an indicator for prediction of NEC in preterm infants with LOS.

Dietary fiber pectin: challenges and potential anti-inflammatory benefits for preterms and newborns

Pectins, a class of dietary fibers abundant in vegetables and fruits, have drawn considerable interest due to their potential anti-inflammatory properties. Numerous studies have indicated that incorporating pectins into infant formula could be a safe strategy for alleviating infant regurgitation and diarrhea. Moreover, pectins have been shown to modulate cytokine production, macrophage activity, and NF-kB expression, all contributing to their anti-inflammatory effects. Despite this promising evidence, the exact mechanisms through which pectins exert these functions and how their structural characteristics influence these processes remain largely unexplored. This knowledge is particularly significant in the context of gut inflammation in developing preterm babies, a critical aspect of necrotizing enterocolitis (NEC), and in children and adults dealing with inflammatory bowel disease (IBD). Our mini review aims to provide an up-to-date compilation of relevant research on the effects of pectin on gut immune responses, specifically focusing on preterms and newborns. By shedding light on the underlying mechanisms and implications of pectin-mediated anti-inflammatory properties, this review seeks to advance our knowledge in this area and pave the way for future research and potential therapeutic interventions.

Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis

Importance

Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants.

Objective

To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials.

Data Sources

MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023.

Study Selection

Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants.

Data Extraction and Synthesis

A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach.

Main Outcomes and Measures

All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization.

Results

A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively).

Conclusions and Relevance

In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.

Factors Influencing Neonatal Gut Microbiome and Health with a Focus on Necrotizing Enterocolitis

Maturational changes in the gut start in utero and rapidly progress after birth, with some functions becoming fully developed several months or years post birth including the acquisition of a full gut microbiome, which is made up of trillions of bacteria of thousands of species. Many factors influence the normal development of the neonatal and infantile microbiome, resulting in dysbiosis, which is associated with various interventions used for neonatal morbidities and survival. Extremely low gestational age neonates (<28 weeks' gestation) frequently experience recurring arterial oxygen desaturations, or apneas, during the first few weeks of life. Apnea, or the cessation of breathing lasting 15-20 s or more, occurs due to immature respiratory control and is commonly associated with intermittent hypoxia (IH). Chronic IH induces oxygen radical diseases of the neonate, including necrotizing enterocolitis (NEC), the most common and devastating gastrointestinal disease in preterm infants. NEC is associated with an immature intestinal structure and function and involves dysbiosis of the gut microbiome, inflammation, and necrosis of the intestinal mucosal layer. This review describes the factors that influence the neonatal gut microbiome and dysbiosis, which predispose preterm infants to NEC. Current and future management and therapies, including the avoidance of dysbiosis, the use of a human milk diet, probiotics, prebiotics, synbiotics, restricted antibiotics, and fecal transplantation, for the prevention of NEC and the promotion of a healthy gut microbiome are also reviewed. Interventions directed at boosting endogenous and/or exogenous antioxidant supplementation may not only help with prevention, but may also lessen the severity or shorten the course of the disease.

Prediction of GutCheck NEC and Its Relation to Severity of Illness and Measures of Deterioration in Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) risk has been shown to arise from multiple sources and risk awareness may be supported using bedside tools.

PURPOSE

The purpose of this research was to examine the extent to which GutCheck NEC was associated with scores for clinical deterioration, severity of illness, and clinical outcome, and further to examine how scores might improve NEC prediction.

METHODS

A retrospective, correlational case-control study with infant data from 3 affiliated neonatal intensive care units was conducted.

RESULTS

Of 132 infants (44 cases, 88 controls), most were 28 weeks of gestation at birth and less (74%). Median age at NEC onset was 18 days (range: 6-34 days), with two-thirds diagnosed before 21 days. At 68 hours of life, higher GutCheck NEC scores were associated with NEC requiring surgery or resulting in death (relative risk ratio [RRR] = 1.06, P = .036), associations that persisted at 24 hours prior to diagnosis (RRR = 1.05, P = .046), and at the time of diagnosis (RRR = 1.05, P = .022) but showed no associations for medical NEC. GutCheck NEC scores were significantly correlated with pediatric early warning scores (PEWS) ( r > 0.30; P < .005) and SNAPPE-II scores ( r > 0.44, P < .0001). Increasing numbers of clinical signs and symptoms were positively associated with GutCheck NEC and PEWS at the time of diagnosis ( r = 0.19, P = .026; and r = 0.25, P = .005, respectively).

IMPLICATIONS FOR PRACTICE AND RESEARCH

GutCheck NEC provides structure to streamline assessment and communication about NEC risk. Yet, it is not intended to be diagnostic. Research is needed on how GutCheck NEC impacts timely recognition and treatment.

Bugs and the barrier: A review of the gut microbiome and intestinal barrier in necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease that affects premature neonates. It frequently results in significant morbidity and mortality for those affected. Years of research into the pathophysiology of NEC have revealed it to be a variable and multifactorial disease. However, there are risk factors associated with NEC including low birth weight, prematurity, intestinal immaturity, alterations in microbial colonization, and history of rapid or formula based enteral feeds (Fig. 1).^1-3 An accepted generalization of the pathogenesis of NEC includes a hyperresponsive immune reaction to insults such as ischemia, starting formula feeds, or alterations in the microbiome with pathologic bacterial colonization and translocation. This reaction causes a hyperinflammatory response disrupting the normal intestinal barrier, allowing abnormal bacterial translocation and ultimately sepsis.^1,2,4 This review will focus specifically on the interactions with the microbiome and intestinal barrier function in NEC.

The effect of oropharyngeal colostrum administration on the clinical outcomes of premature infants: A meta-analysis

BACKGROUND

Preterm complications are now the second leading cause of death in children under five years of age. Colostrum is essential to prevent infection and promote maturation in preterm infants. Guidelines recommend that preterm infants be fed colostrum by the oral and pharyngeal routes as early as possible after birth to provide immune protection; however, due to disease and an uncoordinated sucking and swallowing function, it is challenging to provide colostrum through the oropharyngeal route, which limits the immune protection it provides.

OBJECTIVE

To update the existing meta-analysis, evaluate the effect of oropharyngeal colostrum administration on related outcomes in preterm infants and explore the optimal frequency and duration of oropharyngeal colostrum administration through subgroup analysis.

METHODS

The Cochrane Library, PubMed, Web of Science, ScienceDirect, and Ovid databases were searched for randomized control trials (RCTs) of oropharyngeal colostrum administration for preterm infants. Two researchers screened the literature strictly according to the inclusion and exclusion criteria and evaluated the quality. Primary data and data from the included literature were extracted. Finally, the data were statistically analyzed by the Review Manager 5.3 software.

RESULTS

A total of 1736 preterm infants were included in 16 RCTs. The meta-analysis showed that the incidence of necrotizing enterocolitis, late-onset sepsis, feeding intolerance, and death was lower, the time to full enteral feeding was shorter, and the day of recovery to birth weight was earlier in the intervention group (oropharyngeal colostrum administration group) than in the control group, and this difference was statistically significant. Subgroup analysis: Frequency of oropharyngeal colostrum administration: The incidence of necrotizing enterocolitis and late-onset sepsis in the once every 4 h group was lower than that in the control group, and the time to complete enteral feeding was shorter. Duration of oropharyngeal colostrum administration: In the 1-3 days group and 4-7 days group, the time to full enteral feeding in the intervention group was shorter. In the 8-10 days group, the incidence of necrotizing enterocolitis and late-onset sepsis was lower in the intervention group.

CONCLUSIONS

Oropharyngeal colostrum administration can reduce the incidence of necrotizing enterocolitis, late-onset sepsis, feeding intolerance and mortality, shorten the time to full enteral feeding, and lead to a faster recovery to birth weight in preterm infants. The appropriate oropharyngeal colostrum administration frequency may be 4 h, and the optimal duration may be 8-10 days. Therefore, it is recommended that clinical medical staff implement oropharyngeal colostrum administration for premature infants based on existing evidence.

TWEETABLE ABSTRACT

Oropharyngeal colostrum administration can reduce the incidence of complications in preterm infants and shorten the time to full enteral feeding.

Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects

The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

Butyrate induces development-dependent necrotizing enterocolitis-like intestinal epithelial injury via necroptosis

BACKGROUND

The accumulation of short-chain fatty acids (SCFAs) from bacterial fermentation may adversely affect the under-developed gut as observed in premature newborns at risk for necrotizing enterocolitis (NEC). This study explores the mechanism by which specific SCFA fermentation products may injure the premature newborn intestine mucosa leading to NEC-like intestinal cell injury.

METHODS

Intraluminal injections of sodium butyrate were administered to 14- and 28-day-old mice, whose small intestine and stool were harvested for analysis. Human intestinal epithelial stem cells (hIESCs) and differentiated enterocytes from preterm and term infants were treated with sodium butyrate at varying concentrations. Necrosulfonamide (NSA) and necrostatin-1 (Nec-1) were used to determine the protective effects of necroptosis inhibitors on butyrate-induced cell injury.

RESULTS

The more severe intestinal epithelial injury was observed in younger mice upon exposure to butyrate (p = 0.02). Enterocytes from preterm newborns demonstrated a significant increase in sensitivity to butyrate-induced cell injury compared to term newborn enterocytes (p = 0.068, hIESCs; p = 0.038, differentiated cells). NSA and Nec-1 significantly inhibited the cell death induced by butyrate.

CONCLUSIONS

Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury in NEC is necroptosis. Necroptosis inhibition may represent a potential preventive or therapeutic strategy for NEC.

IMPACT

Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury caused by butyrate in NEC is necroptosis. Necroptosis inhibitors proved effective at significantly ameliorating the enteral toxicity of butyrate and thereby suggest a novel mechanism and approach to the prevention and treatment of NEC in premature newborns.

IS -94INS/DELATTG POLYMORPHISM IN THE NUCLEAR FACTOR KAPPA-B1 GENE (NFKB1) ASSOCIATED WITH NECROTIZING ENTEROCOLITIS?

BACKGROUND

Abnormalities in the different stages of the intestinal maturation process cause metabolic and molecular changes. Among the genetic alterations associated with necrotizing enterocolitis, the -94ins/delATTG polymorphism in NFKB1 gene leads to unregulated activation of the NFKB protein due to an increase in the inherent pro-inflammatory state of the premature intestine.

AIMS

To determine the prevalence of the -94ins/delATTG polymorphism in NFKB1 gene in neonates with and without necrotizing enterocolitis.

METHODS

This is a case-control study, in which 25 neonates were evaluated as the case group and 50 neonates as the control group, of both genders. DNA was extracted from peripheral blood leukocytes, and the site encompassing the polymorphism was amplified by molecular techniques (polymerase chain reaction/polymorphism in restriction fragment length).

RESULTS

Necrotizing enterocolitis was diagnosed in 25 (33%) neonates and, of these, 3 (12%) died. Male gender was more prevalent in both groups (p=0.1613): cases (52%) and controls (62%). Moderate and extreme preterm newborns were predominant in both groups: cases (80%) and controls (88%) (p=0.3036). Low birth weight and extremely low birth weight newborns were the most prevalent in cases (78%), and very low birth weight and extremely low birth weight were the most prevalent in controls (81%) (p=0.1073). Clinical treatment was successful in 72%, and hospital discharge was achieved in 88% of newborns with NEC. The -94ins/delATTG polymorphism in NFKB1 gene was not identified in all the 150 alleles analyzed (100%).

CONCLUSIONS

The absence of the -94ins/delATTG polymorphism in NFKB1 gene in newborns with and without necrotizing enterocolitis does not rule out the possibility of alterations in this and/or in other genes in newborns with this condition, which reinforces the need for further research.

Gut-Brain cross talk: The pathogenesis of neurodevelopmental impairment in necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating condition of multi-factorial origin that affects the intestine of premature infants and results in high morbidity and mortality. Infants that survive contend with several long-term sequelae including neurodevelopmental impairment (NDI)-which encompasses cognitive and psychosocial deficits as well as motor, vision, and hearing impairment. Alterations in the gut-brain axis (GBA) homeostasis have been implicated in the pathogenesis of NEC and the development of NDI. The crosstalk along the GBA suggests that microbial dysbiosis and subsequent bowel injury can initiate systemic inflammation which is followed by pathogenic signaling cascades with multiple pathways that ultimately lead to the brain. These signals reach the brain and activate an inflammatory cascade in the brain resulting in white matter injury, impaired myelination, delayed head growth, and eventual downstream NDI. The purpose of this review is to summarize the NDI seen in NEC, discuss what is known about the GBA, explore the relationship between the GBA and perinatal brain injury in the setting of NEC, and finally, highlight the existing research into possible therapies to help prevent these deleterious outcomes.

Reducing Risk Factors for Necrotizing Enterocolitis: What Is the Recent Evidence and Biologic Plausibility Supporting Probiotics?

BACKGROUND

Development of necrotizing enterocolitis is multifactorial, with contributing factors that are unique to the preterm infant in the neonatal intensive care unit (NICU). The use of probiotics may reduce these risk factors.

PURPOSE

To evaluate evidence of biologic plausibility for probiotic supplementation to mitigate key risk factors implicated in the development of disease and show recent evidence of safety and effectiveness.

DATA SOURCES

A literature survey of electronic databases, including PubMed, Cochrane Database of Systematic Reviews, and CINAHL, was conducted.

STUDY SELECTION

Selection terms included "necrotizing enterocolitis," "probiotics," and "prematurity." Reviews that were included were full text, in English, and published in the last 5 years. Ten systematic reviews of randomized controlled trials were extracted from 749 records. Excluded were studies that used adjuncts to probiotics, such as lactoferrin or prebiotics, and studies of probiotics given antenatally.

DATA EXTRACTION

Two independent reviewers extracted data to AMSTAR 2, a critical appraisal tool for systematic reviews of randomized or nonrandomized studies of healthcare interventions.

RESULTS

All the reviews found statistically significant reductions in necrotizing enterocolitis rates after supplementation with probiotics. None of the reviews reported adverse effects.

IMPLICATION FOR PRACTICE AND RESEARCH

Probiotic supplementation with specific strains reduces risk for necrotizing enterocolitis. To advance probiotic use in the NICU, additional high-quality trials are needed to focus on specific strains or combinations of strains and to evaluate dosing and duration of treatment.Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx .

A Decrease in Hb and Hypoproteinemia: Possible Predictors of Complications in Neonates with Late-Onset Sepsis in a Developing Country

Objective

The main purpose of our study was to determine the predictors of complications in neonates with late-onset sepsis (LOS).

Materials and methods

This was a retrospective cohort study conducted in a neonatal intensive care unit between June 2016 and February 2020. Neonates with LOS were enrolled in this study. According to whether complications were merged after LOS, neonates were divided into a complicated group and a noncomplicated group. The demographic data, perinatal conditions, blood cell count analysis, blood cultures, hypoproteinemia within 1 week after the onset of sepsis and treatment measures were compared between the groups.

Results

A total of 87 neonates with LOS were enrolled in this study. Significant differences were observed between the complicated and noncomplicated groups with regard to hemoglobin (Hb), a decrease in Hb, hypoproteinemia and red blood cell transfusions (P < 0.05). Further comparison found that neonates with LOS who had moderate or severe anemia at the time of sepsis onset were more likely to have complications than those with mild or no anemia. The results of binomial stepwise logistic regression suggested that a decrease in Hb (OR=0.045, P=0.025 < 0.05) and hypoproteinemia (OR=0.266, P=0.007 < 0.05) were independent predictors of complications in neonates with LOS. A receiver operating characteristic analysis showed that the area under the curve was 0.807 for a decrease in Hb.

Conclusion

A decrease in Hb and hypoproteinemia were independent predictors of complications and may help to predict the occurrence of complications in neonates with LOS in the early stage.

Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy

Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. To compare the mortality of primary peritoneal drainage versus primary peritoneal laparotomy as initial surgical intervention for NEC. All data were extracted from PubMed, Embase, and the Cochrane Library. Studies published up to December 2021. Patients with NEC. Studies centered on primary peritoneal drainage and primary peritoneal laparotomy as the initial surgical treatment. Mortality outcomes were available for both interventions. Randomized controlled trials, retrospective cohort studies, and case series in peer-reviewed journals. Language limited to English. Odds ratio (OR) with 95% confidence intervals (CIs) was used to evaluate mortality outcome. Subgroup analyses and linear regression were performed to ascertain the association between mortality pre-specified factors. Data of 1062 patients received peritoneal drainage and 2185 patients received peritoneal laparotomy from five case series, five retrospective cohort studies, and three randomized controlled trials. Peritoneal drainage caused similar mortality (OR 1.49, 95% CI 0.99-2.26) compared with peritoneal laparotomy as initial surgical management for NEC infants. The subgroup analysis of study design, sample size, birth weight, and sex showed similar findings, but inconsistent results were found for country (USA: 1.47, 95% CI 0.90-2.41; Canada: 2.53, 95% CI 0.30-21.48; Australia: 10.29, 95% CI 1.03-102.75; Turkey: 0.09, 95% CI 0.01-0.63) and gestational age (age mean difference < 3: 1.23, 95% CI 0.72-2.11; age mean difference ≥ 3: 2.29, 95% CI 1.04-5.05). No statistically significance was found for the linear regression between mortality and sample size (P = 0.842), gestational age (P = 0.287), birth weight (P = 0.257), sex (P = 0.6). Small sample size, high heterogeneity, NEC, and spontaneous intestinal perforation (SIP) had to be analyzed together, lack of selection criteria for the future selection of an intervention, and no clear, standardized procedures.   Conclusion: There was no significant difference in mortality between peritoneal drainage and laparotomy as initial surgical intervention. The results suggest that either intervention could be used in selected patients. What is Known: • Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. What is New: • No significant difference of mortality between peritoneal drainage and laparotomy as initial surgical intervention.

Antibacterial and anti-inflammatory effects of Lactobacillus reuteri in its biofilm state contribute to its beneficial effects in a rat model of experimental necrotizing enterocolitis

INTRODUCTION

Necrotizing enterocolitis (NEC) remains a significant surgical emergency in neonates. We have demonstrated the efficacy of Lactobacillus reuteri (Lr) in protecting against experimental NEC when administered as a biofilm by incubation with maltose loaded dextranomer microspheres. Lr possesses antimicrobial and anti-inflammatory properties. We developed mutant strains of Lr to examine the importance of its antimicrobial and anti-inflammatory properties in protecting the intestines from NEC.

METHODS

Premature rat pups were exposed to hypoxia/hypothermia/hypertonic feeds to induce NEC. To examine the importance of antimicrobial reuterin and anti-inflammatory histamine, pups received either native or mutant forms of Lr, in either its planktonic or biofilm states, prior to induction of NEC. Intestinal histology was examined upon sacrifice.

RESULTS

Compared to no treatment, administration of a single dose of Lr in its biofilm state significantly decreased the incidence of NEC (67% vs. 18%, p < 0.0001), whereas Lr in its planktonic state had no significant effect. Administration of reuterin-deficient or histamine-deficient forms of Lr, in either planktonic or biofilm states, resulted in significant loss of efficacy.

CONCLUSION

Antimicrobial and anti-inflammatory effects of Lr contribute to its beneficial effects against NEC. This suggests that both infectious and inflammatory components contribute to the etiology of NEC.

Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage

OBJECTIVE

We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015-April 2016) to 200 by December 2018.

STUDY DESIGN

We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures.

RESULTS

After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period.

CONCLUSION

Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period.

KEY POINTS

· This is a quality improvement project to reduce antibiotic usage in NICU.. · Charge nurses should take charge to reduce infections in NICU.. · Central line infections should be reduced to decrease antibiotic usage..

Association of neutrophil to lymphocyte ratio with preterm necrotizing enterocolitis: a retrospective case-control study

Background

There have been few studies on the relationship between the neutrophil to lymphocyte ratio (NLR) and necrotizing enterocolitis (NEC). We conducted a retrospective case-control study to investigate this relationship in preterm neonates.

Methods

A total of 199 preterm neonates diagnosed with NEC between January 2018 and January 2020 were included in this study. For each preterm infant with NEC that was admitted to the neonatal intensive care unit (NICU), controls were preterm neonates (matched for gestation and year of birth) who were not diagnosed with NEC. Exclusion criteria were post-maturity, small or large for gestational age (week of pregnancy), congenital major anomalies, and cyanotic congenital heart disease. Univariate and multivariate logistic regression analyses were used to identify the association between NLR and preterm NEC.

Results

This study included 93 preterm neonates with NEC and 106 matched controls. There were no significant differences in gestational age (GA), birth weight (BW), age, sex, vaginal delivery (VD), chorioamnionitis (CA), and gestational diabetes mellitus (GDM) between the groups. Compared with the control group, the lower and higher NLR levels in the NEC group were statistically different. Following univariate analysis, NLR was a risk factor for NEC (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.00–1.90; P = 0.042), and according to multivariate analysis, risk factors for NEC were NLR ≥ 3.20 and NLR < 1.60, within 1 week before NEC diagnosis. Thus, NLR values of ≥ 1.60 and < 3.20 were determined as the predictive cut-off values for protecting preterm infants from NEC (Model I: OR, 0.20; 95% CI, 0.10–0.40; P < 0.001) and (Model II: OR, 0.10; 95% CI, 0.00–0.40; P < 0.001].

Conclusions

NLR ≥ 1.60 and NLR < 3.20 were associated with a decreased risk of NEC in preterm infants.

The role of ultrasound in necrotizing enterocolitis

Ultrasound has proved to be a useful modality for enhancing the diagnostic accuracy of necrotizing enterocolitis and associated complications. The standard imaging algorithm for evaluating necrotizing enterocolitis includes radiographs and clinical symptoms, the combination of which constitutes the Bell criteria. Major limitations of using the Bell criteria for diagnosing and clinically managing necrotizing enterocolitis include low diagnostic accuracy of radiographs and nonspecific symptomatology of preterm infants. In this regard, US can offer additional insights into bowel health by helping to characterize bowel motility, echogenicity, thickness, pneumatosis and perfusion. Extramural findings such as portal venous gas, nature and extent of ascites, and pneumoperitoneum can also be assessed. Recently, contrast-enhanced US was explored in a case series of preterm bowel disease and its diagnostic utility warrants further investigation. This article reviews the US features of necrotizing enterocolitis and highlights the role of US as a complement to radiographs, as well as the emerging use of contrast-enhanced US in necrotizing enterocolitis.

The Mean Platelet Volume Combined with Procalcitonin as an Early Accessible Marker Helps to Predict the Severity of Necrotizing Enterocolitis in Preterm Infants

Purpose

Methods

Results

Conclusion

Prevention of Necrotizing Enterocolitis

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.

Antibiotic Exposure, Common Morbidities and Main Intestinal Microbial Groups in Very Preterm Neonates: A Pilot Study

Prematurity exposes newborns to increased risks of infections and it is associated with critical morbidities. Preterm infants often require antibiotic therapies that can affect the correct establishment of gut microbiota. The aim of this study was to investigate targeted intestinal bacteria in preterm neonates with common morbidities and receiving antibiotic treatments of variable duration. Stool samples were collected after birth, at 15, 30 and 90 days of life. qPCR quantification of selected microbial groups (Bifidobacterium spp., Bacteroides fragilis group, Enterobacteriaceae, Clostridium cluster I and total bacteria) was performed and correlation between their levels, the duration of antibiotic treatment and different clinical conditions was studied. An increasing trend over time was observed for all microbial groups, especially for Bifdobacterium spp. Prolonged exposure to antibiotics in the first weeks of life affected Clostridium and B. fragilis levels, but these changes no longer persisted at 90 days of life. Variations of bacterial counts were associated with the length of hospital stay, feeding and mechanical ventilation. Late-onset sepsis and patent ductus arteriosus reduced the counts of Bifidobacterium, whereas B. fragilis was influenced by compromised respiratory conditions. This study can be a start point for the identification of microbial biomarkers associated with some common morbidities and tailored strategies for a healthy microbial development.

Dominant bacteria and influencing factors of early intestinal colonization in very low birth weight infants: A prospective cohort study

Background

The intestine of newborns is colonized by bacteria immediately after birth. This study explored dominant bacteria and influencing factors of early intestinal colonization in the early life of very low birth weight infants (VLBWI).

Methods

We enrolled 81 VLBWI and collected anal swabs at 24 h, 7th, 14th and 21st day after birth. We conducted bacterial culture for anal swabs, then selected the colony with obvious growth advantages in the plate for further culture and identification. Afterward, we analyzed the distribution and influencing factors of intestinal dominant microbiota combined with clinical data.

Results

A total of 300 specimens were collected, of which 62.67% (188/300) had obvious dominant bacteria, including 29.26% (55/188) Gram‐positive bacteria and 70.74% (133/188) Gram‐negative bacteria. The top five bacteria with the highest detection rates were Klebsiella pneumoniae, Escherichia coli, Enterococcus faecium, Enterococcus faecalis and Serratia marcescens. Meconium‐stained amniotic fluid and chorioamnionitis were correlated with intestinal bacterial colonization within 24 h of birth. Mechanical ventilation and antibiotics were independent risk factors affecting colonization. Nosocomial infection of K. pneumoniae and S. marcescens were associated with intestinal colonization. The colonization rates of K. pneumoniae, E. coli, E. faecium, and E. faecalis increased with the birth time.

Conclusions

The colonization rate in the early life of VLBWI increased over time and the predominant bacteria were Gram‐negative bacteria. Meconium‐stained amniotic fluid and chorioamnionitis affect intestinal colonization in early life. Mechanical ventilation and antibiotics were independent risk factors for intestinal bacterial colonization. The nosocomial infection of some bacteria was significantly related to intestinal colonization.

Fetal-neonatal exposure to antibiotics and NEC development: A systematic review and meta-analysis

BACKGROUND

Fetal and neonatal exposure to antibiotics may contribute to the development of necrotizing enterocolitis (NEC) in preterm infants. This systematic review and meta-analysis investigate whether exposure to third trimester maternal antibiotics (MAB) and/or prolongation of empirical antibiotics (PEAB) are associated with NEC development in preterms.

METHOD

We included observational and randomized controlled studies, including those on preterm or very low birth weight (VLBW) infants, from MEDLINE and EMBASE, published between 1990 and June 2021. Exposure was defined as third trimester MAB and/or PEAB. The two reviewers independently performed study selection, data extraction, and quality assessment.

RESULTS

Three cohort studies compared third trimester MAB with no antibiotics. MAB was associated with lower NEC incidence, unadjusted pooled odds ratio (OR) is 0.57 (95% CI: 0.35-0.93). Twelve cohort studies showed that PEAB was associated with an increased risk of NEC. Ten observational cohort studies show an unadjusted OR of 2.72 (1.65-4.47), and two case-control studies show an unadjusted mean difference of 2.31 (0.94-3.68). Moderate to substantial heterogeneity was observed but decreased in studies with low risk of bias and large sample size.

CONCLUSION

Evidence suggests an association between MAB and decreased risk of NEC and an association between PEAB and increased risk of NEC. Further studies should confirm these associations and explore causality.

SYSTEMATIC REVIEW REGISTRATION

identifier [CRD42022304937].

The Role of Dietary Fats in the Development and Prevention of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a significant cause of mortality and morbidity in preterm infants. The pathogenesis of NEC is not completely understood; however, intestinal immaturity and excessive immunoreactivity of intestinal mucosa to intraluminal microbes and nutrients appear to have critical roles. Dietary fats are not only the main source of energy for preterm infants, but also exert potent effects on intestinal development, intestinal microbial colonization, immune function, and inflammatory response. Preterm infants have a relatively low capacity to digest and absorb triglyceride fat. Fat may thereby accumulate in the ileum and contribute to the development of NEC by inducing oxidative stress and inflammation. Some fat components, such as long-chain polyunsaturated fatty acids (LC-PUFAs), also exert immunomodulatory roles during the early postnatal period when the immune system is rapidly developing. LC-PUFAs may have the ability to modulate the inflammatory process of NEC, particularly when the balance between n3 and n6 LC-PUFAs derivatives is maintained. Supplementation with n3 LC-PUFAs alone may have limited effect on NEC prevention. In this review, we describe how various fatty acids play different roles in the pathogenesis of NEC in preterm infants.

Probiotics, Prebiotics, and Synbiotics for the Prevention of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a major cause of morbidity and mortality in preterm infants. The exact mechanism by which NEC develops is poorly understood however there is growing evidence to suggest that perturbations in the early-life gut microbiota composition increase the risk for NEC. Modulation of the gut microbiota with probiotics, prebiotics, or in combination (synbiotics) is an area which has attracted intense interest in recent years. In this narrative review, we present an overview of the role of the gut microbiota in the pathogenesis of NEC. We also examine the evidence currently available from randomized controlled trials, observational studies, systematic reviews, and meta-analysis examining the role of probiotics, prebiotics, and synbiotics in reducing the risk of or preventing NEC. Current clinical practice guidelines with recommendations on the routine administration of probiotics to preterm infants for NEC are also explored.

Free threonine in human breast milk is related to infant intestinal microbiota composition

BACKGROUND

Accumulating evidence indicates that free amino acids (FAA) might be bioactive compounds with potential immunomodulatory capabilities. However, the FAA composition in human milk is still poorly characterized with respect to its correlation to maternal serum levels and its physiological significance for the infant. Studies addressing the relation of human milk FAA to the infants' intestinal microbiota are still missing.

METHODS

As part of a pilot study, maternal serum and breast milk FAA concentrations as well as infant intestinal microbiota (16S rRNA) were determined 2 months after birth. The study cohort consisted of 41 healthy mothers and their term delivered, healthy infants with normal birthweight. The relationship between maternal serum and milk FAA was determined by correlation analyses. Associations between (highly correlated) milk FAA and infant intestinal beta diversity were tested using PERMANOVA, LefSe and multivariate regression models adjusted for common confounders.

RESULTS

Seven breast milk FAA correlated significantly with serum concentrations. One of these, threonine showed a negative association with abundance of members of the class Gammaproteobacteria (R²adj = 17.1%, p = 0.006; β= - 0.441). In addition, on the level of families and genera, threonine explained 23.2% of variation of the relative abundance of Enterobacteriaceae (R²adj; p = 0.001; β = - 0.504) and 11.1% of variability in the abundance of Escherichia/Shigella (R²adj, p = 0.025; β  = - 0.368), when adjusted for confounders.

CONCLUSION

Our study is the first to suggest potential interactions between breast milk FAA and infant gut microbiota composition during early lactation. The results might be indicative of a potential protective role of threonine against members of the Enterobacteriaceae family in breast-fed infants. Still, results are based on correlation analyses and larger cohorts are needed to support the findings and elucidate possible underlying mechanisms to assess the complex interplay between breast milk FAA and infant intestinal microbiota in detail.

CD16+CD163+ monocytes traffic to sites of inflammation during necrotizing enterocolitis in premature infants

Necrotizing enterocolitis (NEC) is a severe gastrointestinal complication of prematurity. Using suspension and imaging mass cytometry coupled with single-cell RNA sequencing, we demonstrate severe inflammation in patients with NEC. NEC mucosa could be subtyped by an influx of three distinct neutrophil phenotypes (immature, newly emigrated, and aged). Furthermore, CD16⁺CD163⁺ monocytes/Mϕ, correlated with newly emigrated neutrophils, were specifically enriched in NEC mucosa, found adjacent to the blood vessels, and increased in circulation of infants with surgical NEC, suggesting trafficking from the periphery to areas of inflammation. NEC-specific monocytes/Mϕ transcribed inflammatory genes, including TREM1, IL1A, IL1B, and calprotectin, and neutrophil recruitment genes IL8, CXCL1, CXCL2, CXCL5 and had enrichment of gene sets in pathways involved in chemotaxis, migration, phagocytosis, and reactive oxygen species generation. In summary, we identify a novel subtype of inflammatory monocytes/Mϕ associated with NEC that should be further evaluated as a potential biomarker of surgical NEC and a target for the development of NEC-specific therapeutics.

Risk factors of necrotizing enterocolitis in neonates with sepsis: A retrospective case-control study

Sepsis, a severe infectious disease in the neonatal period, is considered a risk factor for necrotizing enterocolitis (NEC). To investigate the specific risk factors for NEC in septic infants, septic infants admitted to our center from January 2010 to April 2018 were included. Septic neonates with proven NEC (Bell's stage ⩾II) were enrolled in the NEC group, and those without NEC were enrolled in the control group. Demographics, clinical characteristics, and risk factors were compared between the two groups. Univariate and logistic regression analyses were used to evaluate the potential risk factors for NEC. A total of 610 septic neonates were included, of whom 78 (12.8%) had complicated NEC. The univariate analysis indicated that infants with NEC had a lower birth weight, a lower gestational age, and older age on admission than those without NEC (P < 0.05). Higher rates of anemia, prolonged rupture of membranes (PROM) (⩾18 h), pregnancy-induced hypertension, late-onset sepsis (LOS), red blood cell transfusion and hypoalbuminemia were observed in the NEC group than in the non-NEC group (P<0.05). Logistic regression analysis revealed LOS (P = 0.000), red blood cell transfusion (P = 0.001) and hypoalbuminemia (P = 0.001) were associated with the development of NEC. Among NEC infants, those who needed red blood cell transfusion had a longer hospitalization duration than those who did not need transfusion (P < 0.05). LOS, red blood cell transfusion and hypoalbuminemia were independent risk factors for the development of NEC in infants with sepsis. Taking measures to reduce the occurrence of hypoproteinemia and severe anemia may help to reduce the occurrence of NEC in septic neonates.

Acceleration of Small Intestine Development and Remodeling of the Microbiome Following Hyaluronan 35 kDa Treatment in Neonatal Mice

The beneficial effects of human milk suppressing the development of intestinal pathologies such as necrotizing enterocolitis in preterm infants are widely known. Human milk (HM) is rich in a multitude of bioactive factors that play major roles in promoting postnatal maturation, differentiation, and the development of the microbiome. Previous studies showed that HM is rich in hyaluronan (HA) especially in colostrum and early milk. This study aims to determine the role of HA 35 KDa, a HM HA mimic, on intestinal proliferation, differentiation, and the development of the intestinal microbiome. We show that oral HA 35 KDa supplementation for 7 days in mouse pups leads to increased villus length and crypt depth, and increased goblet and Paneth cells, compared to controls. We also show that HA 35 KDa leads to an increased predominance of Clostridiales Ruminococcaceae, Lactobacillales Lactobacillaceae, and Clostridiales Lachnospiraceae. In seeking the mechanisms involved in the changes, bulk RNA seq was performed on samples from the terminal ileum and identified upregulation in several genes essential for cellular growth, proliferation, and survival. Taken together, this study shows that HA 35 KDa supplemented to mouse pups promotes intestinal epithelial cell proliferation, as well as the development of Paneth cells and goblet cell subsets. HA 35 KDa also impacted the intestinal microbiota; the implications of these responses need to be determined.

A significant decrease in hemoglobin concentrations may predict occurrence of necrotizing enterocolitis in preterm infants with late-onset sepsis

OBJECTIVE

This study aimed to examine the clinical value of a decrease in hemoglobin concentration (HC) after the onset of sepsis for predicting occurrence of necrotizing enterocolitis (NEC) in preterm infants with late-onset sepsis.

METHODS

We performed a retrospective cohort study between January 2015 and January 2020. Premature neonates (gestational age <37 weeks) with late-onset sepsis (age >3 days) were enrolled. According to the degree of reduction in HC, neonates were divided into the non-decrease group, mild decrease group, and severe decrease group. Demographic data, perinatal conditions, blood cell count analysis, blood culture, and treatment measures were compared.

RESULTS

Eighty premature infants with sepsis were studied. The mortality rate and incidence of NEC were significantly higher in the severe decrease group than in the non-decrease and mild decrease groups. Significant differences were observed in the decrease in HC, red blood cell transfusion, and ventilator application between the NEC and non-NEC groups. A significant decrease in HC was an independent risk factor for NEC in preterm infants with sepsis.

CONCLUSION

A significant decrease in HC is an independent risk factor for NEC and may predict the occurrence of NEC in preterm infants with sepsis.

It's all in the milk: chondroitin sulfate as potential preventative therapy for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating condition affecting up to 5% of neonatal intensive care unit (NICU) admissions. Risk factors include preterm delivery, low birth weight, and antibiotic use. The pathogenesis is characterized by a combination of intestinal ischemia, necrosis of the bowel, reperfusion injury, and sepsis typically resulting in surgical resection of afflicted bowel. Targeted medical therapy remains elusive. Chondroitin sulfate (CS) holds the potential to prevent the onset of NEC through its anti-inflammatory properties and protective effect on the gut microbiome. The purpose of this review is to outline the many properties of CS to highlight its potential use in high-risk infants and attenuate the severity of NEC. The purpose of this review is to (1) discuss the interaction of CS with the infant microbiome, (2) review the anti-inflammatory properties of CS, and (3) postulate on the potential role of CS in preventing NEC. IMPACT: NEC is a costly medical burden in the United States. Breast milk is the best preventative measure for NEC, but not all infants in the NICU have access to breast milk. Novel therapies and diagnostic tools are needed for NEC. CS may be a potential therapy for NEC due to its potent anti-inflammatory properties. CS could be added to the formula in an attempt to mitigate breast milk disparities.

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.

Colonization of Supplemented Bifidobacterium breve M-16V in Low Birth Weight Infants and Its Effects on Their Gut Microbiota Weeks Post-administration

The colonization and persistence of probiotics introduced into the adult human gut appears to be limited. It is uncertain, however, whether probiotics can successfully colonize the intestinal tracts of full-term and premature infants. In this study, we investigated the colonization and the effect of oral supplementation with Bifidobacterium breve M-16V on the gut microbiota of low birth weight (LBW) infants. A total of 22 LBW infants (12 infants in the M-16V group and 10 infants in the control group) were enrolled. B. breve M-16V was administrated to LBW infants in the M-16V group from birth until hospital discharge. Fecal samples were collected from each subject at weeks (3.7-9.3 weeks in the M-16V group and 2.1-6.1 weeks in the control group) after discharge. qPCR analysis showed that the administrated strain was detected in 83.3% of fecal samples in the M-16V group (at log₁₀ 8.33 ± 0.99 cell numbers per gram of wet feces), suggesting that this strain colonized most of the infants beyond several weeks post-administration. Fecal microbiota analysis by 16S rRNA gene sequencing showed that the abundance of Actinobacteria was significantly higher (P < 0.01), whereas that of Proteobacteria was significantly lower (P < 0.001) in the M-16V group as compared with the control group. Notably, the levels of the administrated strain and indigenous Bifidobacterium bacteria were both significantly higher in the M-16V group than in the control group. Our findings suggest that oral administration of B. breve M-16V led to engraftment for at least several weeks post-administration and we observed a potential overall improvement in microbiota formation in the LBW infants' guts.

The Life-Long Role of Nutrition on the Gut Microbiome and Gastrointestinal Disease

Bacterial colonization of the intestines occurs during the first 2 years of life. Homeostasis of the gut microbiome is established to foster normal intestinal immune development for adulthood. Derangements in this process can interfere with immune function and increase an individual's risk for gastrointestinal disorders. We discuss the role of diet and the microbiome on the onset of such disorders. We examine how micronutrients, prebiotics, and probiotics modulate disease pathogenesis. We discuss how diet and abnormal microbial colonization impact extraintestinal organs. Understanding the communication of nutrition and the microbiome offers exciting opportunities for therapeutics.

Administration of extracellular vesicles derived from human amniotic fluid stem cells: a new treatment for necrotizing enterocolitis

PURPOSE

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease. Amniotic fluid stem cells (AFSC) improve NEC injury but human translation remains difficult. We aimed to evaluate the use of extracellular vesicles (EV) derived from human AFSC.

METHODS

Human AFSC (hAFSC) were cultured according to the protocol (Celprogen Inc., California, U.S.A.). Conditioned medium was obtained, ultra-centrifuged, and EV were suspended in phosphate-buffered saline (PBS). C57BL/6 pups were grouped into: (1) breast-fed (Control, n = 11); (2) NEC + placebo (NEC + PBS; n = 10); and (3) NEC + treatment (NEC + EV; n = 11). NEC was induced post-natal days P5-9 by (A) gavage feeding hyperosmolar formula; (B) hypoxia for 10 min; and (C) lipopolysaccharide. Intra-peritoneal injections of PBS or hAFSC-EV were given on P6-7. All animals were sacrificed on P9 and terminal ileum harvested.

RESULTS

hAFSC-EV administration reduced intestinal injury (p = 0.0048), NEC incidence (score ≥ 2), and intestinal inflammation (IL-6 p < 0.0001; TNF-α p < 0.0001). Intestinal stem cell expression (Lgr5 +) and cellular proliferation (Ki67) were enhanced above control levels following hAFSC-EV administration (Lgr5 p = 0.0003; Ki67 p < 0.0001).

CONCLUSION

hAFSC-EV administration reduced intestinal NEC injury and inflammation while increasing stem cell expression and cellular proliferation. hAFSC-EV administration may induce similar beneficial effects to exogenous stem cells.

TFF3 mediates the NF-κB/COX2 pathway to regulate PMN-MDSCs activation and protect against necrotizing enterocolitis

Intestinal trefoil factor 3 (TFF3) plays an important role in repairing the intestinal mucosa. However, the detailed mechanism regarding immune regulation by TFF3 is not well defined. Here, we reported that treatment of mouse BM cells and human peripheral blood mononuclear cells from healthy volunteers with TFF3 activated polymorphnuclear myeloid-derived suppressor cells (PMN-MDSCs) in vitro. We also found that prostaglandin E2 is a major TFF3-mediated MDSC target, and that NF-κB/COX2 signaling was involved in this process. Moreover, TFF3 treatment or transfer of TFF3-derived PMN-MDSCs (TFF3-MDSCs) to experimental necrotizing enterocolitis (NEC) mice caused PMN-MDSC accumulation in the lamina propria (LP), which was associated with decreased intestinal inflammation, permeability, bacterial loading, and prolonged survival. Interestingly, no NEC severity remission was observed in Rag1 KO mice that were given TFF3-MDSCs, but coinjection with CD4⁺ T cells significantly relieved NEC inflammation. Overall, TFF3 mediates the NF-κB/COX2 pathway to regulate PMN-MDSC activation and attenuates NEC in a T-cell-dependent manner, which suggests a novel mechanism in preventing NEC occurrence.

Efficacy of Docosahexaenoic Acid for the Prevention of Necrotizing Enterocolitis in Preterm Infants: A Randomized Clinical Trial

Necrotizing enterocolitis (NEC) is an inflammatory bowel disease and a leading cause of morbidity and mortality in preterm infants. In this study, a randomized double-blind parallel-group (1:1) trial was carried out in two neonatal intensive care units of two tertiary hospitals. Two hundred and twenty-five preterm newborns with an expected functional gastrointestinal tract were recruited and received an enteral dose of 75 mg of docosahexaenoic acid (DHA)/kg body weight or high-oleic sunflower oil daily for 14 days from the first enteral feed after birth. Confirmed NEC was evaluated with Bell’s scale from stage ≥ IIa. Two hundred and fourteen randomized infants were analyzed in terms of the intent-to-treat (DHA-group: n = 105; control-group: n = 109); data for two hundred infants were analysed per protocol. Confirmed NEC was lower in infants from the DHA-group compared with the control-group (0/100 vs. 7/100; p = 0.007), with RR = 0.93 (95% CI 0.881 to 0.981), risk difference = −7%, (95% CI −12.00 to −1.99), and number needed-to-treat = 15 (95% CI 8.3 to 50). Intent-to-treat analysis showed a lower level of treatment failure in the DHA-group compared with the control-group (6/105 (6%) vs. 16/109 (15%); p = 0.03, RR = 0.905, (95% CI 0.826 to 0.991)). The results after multivariate-regression analysis remained significant. Adverse events (apart from the incidence of NEC) were not different between groups. A daily dose of DHA for 14 days starting with the first enteral feed may prevent NEC in preterm infants.

Routine Early Antibiotic Use in SymptOmatic Preterm Neonates: A Pilot Randomized Controlled Trial

We enrolled 98 infants (gestational age <33 weeks) in a pilot randomized trial of antibiotics vs no antibiotics; 55 were randomized (lower maternal infectious risk; symptoms expected for gestation). Adverse events did not differ significantly between the randomization arms. This trial establishes a framework for a larger multicentered trial.

The role of integrins in inflammation and angiogenesis

Integrins are heterodimeric transmembrane cell adhesion molecules made up of alpha (α) and beta (β) subunits arranged in numerous dimeric pairings. These complexes have varying affinities to extracellular ligands. Integrins regulate cellular growth, proliferation, migration, signaling, and cytokine activation and release and thereby play important roles in cell proliferation and migration, apoptosis, tissue repair, as well as in all processes critical to inflammation, infection, and angiogenesis. This review presents current evidence from human and animal studies on integrin structure and molecular signaling, with particular emphasis on signal transduction in infants. We have included evidence from our own laboratory studies and from an extensive literature search in databases PubMed, EMBASE, Scopus, and the electronic archives of abstracts presented at the annual meetings of the Pediatric Academic Societies. To avoid bias in identification of existing studies, key words were short-listed prior to the actual search both from anecdotal experience and from PubMed's Medical Subject Heading (MeSH) thesaurus. IMPACT: Integrins are a family of ubiquitous αβ heterodimeric receptors that interact with numerous ligands in physiology and disease. Integrins play a key role in cell proliferation, tissue repair, inflammation, infection, and angiogenesis. This review summarizes current evidence from human and animal studies on integrin structure and molecular signaling and promising role in diseases of inflammation, infection, and angiogenesis in infants. This review shows that integrin receptors and ligands are novel therapeutic targets of clinical interest and hold promise as novel therapeutic targets in the management of several neonatal diseases.

Predictive Indicators for Necrotizing Enterocolitis With the Presence of Portal Venous Gas and Outcomes of Surgical Interventions

Objectives: Portal venous gas (PVG) was an important clinical sign in stage II or III necrotizing enterocolitis (NEC) in preterm neonates. Not a proper predictive indicator was found to predict the diseases (NEC with the presence of PVG) up to now. There is a need to put forward predictive indicators and compare the predictive effects among them. Methods: We conducted a retrospective study of preterm neonates with NEC-PVG (n = 61) or NEC-non PVG (n = 62) from 2014 to 2021. Predictive indicators were put forward and determined by receiver operating characteristic curve analysis. An analysis of the surgical interventions and their outcomes was performed. Results: The incidence rate of NEC among preterm neonates was 4.99%; surgical and conservative interventions accounted for 20.47 and 75.07%, and the mortality rate was 0.03%. The composition ratio of shock in the NEC-PVG group increased 13.2% (P = 0.029). C-reactive protein, fibrinogen degradation product, and blood glucose had better predictive effects in the predictive indicators (P < 0.05). Intestinal necrosis and subependymal hemorrhage in the outcomes of surgical interventions had a strong relationship with the presence of PVG in NEC II/III (P < 0.05). Conclusion: Early and reasonable use of antibiotics, improvement of coagulation function, rectification of acidosis, and decreased blood glucose could cut down the occurrence of the disease (NEC with the presence of PVG). Except for subependymal hemorrhage and intestinal necrosis, NEC with the presence of PVG did not increase the occurrence of other outcomes after surgery.

Global hypermethylation of intestinal epithelial cells is a hallmark feature of neonatal surgical necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) remains one of the overall leading causes of death in premature infants, and the pathogenesis is unpredictable and not well characterized. The aim of our study was to determine the molecular phenotype of NEC via transcriptomic and epithelial cell-specific epigenomic analysis, with a specific focus on DNA methylation.

METHODS

Using laser capture microdissection, epithelial cell-specific methylation signatures were characterized by whole-genome bisulfite sequencing of ileal and colonic samples at the time of surgery for NEC and after NEC had healed at reanastomosis (n = 40). RNA sequencing was also performed to determine the transcriptomic profile of these samples, and a comparison was made to the methylome data.

RESULTS

We found that surgical NEC has a considerable impact on the epigenome by broadly increasing DNA methylation levels, although these effects are less pronounced in genomic regions associated with the regulation of gene expression. Furthermore, NEC-related DNA methylation signatures were influenced by tissue of origin, with significant differences being noted between colon and ileum. We also identified numerous transcriptional changes in NEC and clear associations between gene expression and DNA methylation.

CONCLUSIONS

We have defined the intestinal epigenomic and transcriptomic signatures during surgical NEC, which will advance our understanding of disease pathogenesis and may enable the development of novel precision medicine approaches for NEC prediction, diagnosis and phenotyping.

The Role of Human Milk in Decreasing Necrotizing Enterocolitis Through Modulation of the Infant Gut Microbiome: A Scoping Review

BACKGROUND

Necrotizing enterocolitis is associated with a high incidence of morbidity and mortality in premature infants. Human milk minimizes necrotizing enterocolitis risk, although the mechanism of protection is not thoroughly understood. Increasingly, dysbiosis of the infant gut microbiome, which is affected by infant diet, is hypothesized to play a role in necrotizing enterocolitis pathophysiology.

RESEARCH AIM

The aim of this scoping review was to summarize the state of the science regarding the hypothesis that the gut microbiome composition is a mediator of the relationship between human milk and decreased incidence of necrotizing enterocolitis within a sample of human infants.

METHODS

Electronic databases and reference lists were searched for peer-reviewed primary research articles addressing the link between human milk, gut microbiome composition, and subsequent incidence of necrotizing enterocolitis among human infants.

RESULTS

A total of four studies met criteria for inclusion in this review. Of these, evidence supporting the link between human milk, gut microbiome composition, and necrotizing enterocolitis was found in two (50%) studies.

CONCLUSION

Some evidence linking all three variables is provided in this review. Given the small number of available studies, and the limitations of those studies, more research is urgently needed to thoroughly understand the protection against necrotizing enterocolitis gained through the provision of human milk.

A role for neonatal bacteremia in deaths due to intestinal perforation: spontaneous intestinal perforation compared with perforated necrotizing enterocolitis

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.

Effect of Maternal Diet and Milk Lipid Composition on the Infant Gut and Maternal Milk Microbiomes

Inter-subject variability in human milk microbiome is well known; however, its origins and possible relationship to the mother’s diet are still debated. We investigated associations between maternal nutrition, milk fatty acids composition and microbiomes in mother–infant dyads. Breast milk and infant fecal samples were collected across three time points (one week, one month and three months postpartum) from 22 mother–infant pairs. Food frequency questionnaires for the months of pregnancy and three months postpartum were collected. Milk fatty acids were analyzed by GC–MS and the microbiome in breast milk and infant feces was determined by 16S rRNA sequencing. Statistical interactions were computed using Spearman’s method and corrected for multiple comparisons. We found significant negative correlation between Streptococcus relative abundance in maternal milk and intake of unsaturated fatty acids and folic acid at one month postpartum. At three months postpartum, vitamin B-12 consumption was significantly associated with a single operational taxonomic unit belonging to Streptococcus. Comparison between milk microbiome and lipid composition showed, one-month postpartum, significant negative correlation between Streptococcus relative abundance and the abundance of oleic acid. Additional correlations were detected between Staphylococcus hominis and two medium-chain saturated fatty acids. Our results reinforce the hypothesis that maternal nutrition may affect milk microbiome.

Probiotic Supplementation During the Perinatal and Infant Period: Effects on Gut Dysbiosis and Disease

The perinatal period is crucial to the establishment of lifelong gut microbiota. The abundance and composition of microbiota can be altered by several factors such as preterm delivery, formula feeding, infections, antibiotic treatment, and lifestyle during pregnancy. Gut dysbiosis affects the development of innate and adaptive immune responses and resistance to pathogens, promoting atopic diseases, food sensitization, and infections such as necrotizing enterocolitis (NEC). Recent studies have indicated that the gut microbiota imbalance can be restored after a single or multi-strain probiotic supplementation, especially mixtures of Lactobacillus and Bifidobacterium strains. Following the systematic search methodology, the current review addresses the importance of probiotics as a preventive or therapeutic tool for dysbiosis produced during the perinatal and infant period. We also discuss the safety of the use of probiotics in pregnant women, preterm neonates, or infants for the treatment of atopic diseases and infections.