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Garg PM, Pippin M, Zhang M, Ware J, Nelin S, Paschal J, Varshney N, Hillegass WB. Clinical Correlates of Moderate-to-Severe Bronchopulmonary Dysplasia in Preterm Infants following Surgical Necrotizing Enterocolitis. Am J Perinatol 2024; 41:1348-1358. [PMID: 35858647 PMCID: PMC10278056 DOI: 10.1055/a-1904-9194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of the study is to determine clinical correlates of moderate to severe bronchopulmonary dysplasia (BPD) in preterm infants following surgical necrotizing enterocolitis (NEC). STUDY DESIGN This is a retrospective, single-center cohort study comparing patients with moderate to severe BPD to patients with non/mild BPD among surgical NEC infants. BPD was defined by NIH 2001 consensus definition. RESULTS Of 92 consecutive neonates with surgical NEC, 77% (71/92) had moderate/severe BPD and 22% (21/92) had non/mild BPD. The patent ductus arteriosus (PDA) was significantly higher in those developing moderate/severe BPD (67.6% [48/71]) than non/mild BPD (28.6% [6/21]; p = 0.001). Postoperatively, infants with moderate/severe BPD had more severe acute kidney injury (AKI; 67.6 [48/71] vs. 28.6% [6/21]; p = 0.001), were intubated longer (40.5 [interquartile (IQR): 12, 59] vs. 6 days [IQR: 2, 13]; p <0.001), received more parenteral nutrition (109 [IQR: 77, 147] vs. 55 days [IQR: 19, 70]; p <0.001), developed higher surgical morbidity (46.5 [33/71] vs. 14.3% [3/21]; p = 0.008), had more intestinal failure (62.5 vs. 13.3%; p <0.001), required a longer hospital stay (161 [IQR: 112, 186] vs. 64 days [IQR: 20, 91]; p <0.001), and were more likely to need home oxygen. In a multivariable analysis, lower birth weight (OR = 0.3, [95% confidence interval (CI): 0.1-0.5]; p = 0.001), PDA (OR = 10.3, [95% CI: 1.6-65.4]; p = 0.014), and longer parenteral nutritional days (OR = 8.8; [95% CI: 2.0-43.0]; p = 0.005) were significantly and independently associated with higher odds of moderate/severe versus non-/mild BPD. CONCLUSION Development of moderate/severe BPD occurred in the majority of preterm infants with surgical NEC in this consecutive series. Preterm infants with moderate/severe BPD were more likely to have a PDA before NEC. Development of moderate/severe BPD was associated with significantly greater burden and duration of postoperative morbidity following surgical NEC. Identifying surgical NEC infants at increased risk of moderate/severe BPD and developing lung protection strategies may improve surgical NEC outcomes. KEY POINTS · Three-fourths of preterm infants experienced severe lung injury following surgical NEC.. · The infants with severe moderate/severe BPD were most likely associated with greater duration of postoperative morbidity.. · There is need to understand and develop lung protective strategies in infants with surgical NEC..
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Affiliation(s)
- Parvesh M. Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Melissa Pippin
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mengna Zhang
- Department of Data Science, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jennifer Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sarah Nelin
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jaslyn Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Neha Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - William B. Hillegass
- Department of Data Science, University of Mississippi Medical Center, Jackson, Mississippi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Garg PP, Shenberger J, South AM, Garg PM. Necrotizing Enterocolitis-Associated Acute Kidney Injury-Transforming the Paradigm. Am J Perinatol 2024. [PMID: 38768643 DOI: 10.1055/a-2330-1244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Necrotizing enterocolitis (NEC) is one of the most common conditions requiring emergency surgery in the neonatal intensive care unit and is associated with a septic shock-like state contributing to multiorgan dysfunction. NEC affects 6 to 10% of very low-birth-weight infants and remains a leading cause of death. The occurrence of severe acute kidney injury (AKI) following surgical NEC is a harbinger of multiple morbidities. This review presents current evidence about the clinical impact of NEC-associated AKI on the clinical outcomes. Studies evaluating nephroprotective strategies to prevent AKI and its consequences are greatly needed to improve the postoperative recovery and clinical outcomes in neonates with NEC. Future observational studies and clinical trials in preterm infants with NEC prioritize measuring short-term (AKI) and longer term (chronic kidney disease) kidney outcomes. KEY POINTS: · Severe AKI is common following surgical NEC.. · Severe AKI following NEC is associated with poor clinical outcomes.. · Studies evaluating nephroprotective strategies to prevent AKI and its consequences are needed.. IMPACT: · Severe AKI (stage 2 and 3) occurs in 32.6% of neonates after NEC diagnosis and in 58.7% following surgical NEC diagnosis.. · NEC-associated AKI is associated with severe postoperative course, moderate-to-severe bronchopulmonary dysplasia, surgical complications, brain injury, and longer hospital stay in preterm infants.. · Severity of NEC-associated AKI can be utilized by bedside providers for the prognostication of clinical outcomes in preterm infants..
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Affiliation(s)
- Padma P Garg
- Department of Pediatrics Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jeffrey Shenberger
- Department of Pediatrics/Neonatology, Connecticut Children's, Hartford, Connecticut
| | - Andrew M South
- Section of Nephrology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Parvesh M Garg
- Department of Pediatrics/Neonatology, Wake Forest University, Winston-Salem, North Carolina
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Sokou R, Mantzios P, Tsantes AG, Parastatidou S, Ioakeimidis G, Lampridou M, Kokoris S, Iacovidou N, Houhoula D, Vaiopoulos AG, Piovani D, Bonovas S, Tsantes AE, Konstantinidi A. Assessment of hemostatic profile in neonates with necrotizing enterocolitis using Rotational Thromboelastometry (ROTEM). Pediatr Res 2024; 95:1596-1602. [PMID: 38092966 DOI: 10.1038/s41390-023-02958-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/16/2023] [Accepted: 11/27/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND This study aimed to explore the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and to investigate if ROTEM parameters have the capacity to play a role in the differentiation of NEC from sepsis at the disease onset. METHODS This observational study included 62 neonates (mean gestational age 31.6 weeks and mean birth weight 1620g) hospitalized in a neonatal intensive care unit. The neonates were categorized in three groups: neonates with NEC (Bell stage II and above), neonates with sepsis and healthy neonates and they were matched 1:1:1 with regards to gestational age, delivery mode, and sex. Clinical, laboratory data as well as measurements of ROTEM parameters at disease onset were recorded. RESULTS ROTEM parameters differed between neonates with NEC and neonates with sepsis, indicating that NEC results in accelerated clot formation and higher clot strength compared to sepsis. The EXTEM CFT and A10 parameters demonstrated the highest diagnostic performance for NEC in terms of discrimination between NEC and sepsis (AUC, 0.997; 95% CI: 0.991-1.000 and 0.973; 95% CI: 0.932-1.000, respectively). CONCLUSIONS Neonates with NEC manifested accelerated clot formation and higher clot strength compared to septic and healthy neonates, as these were expressed by ROTEM parameters. IMPACT This work reports data on the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and the capacity of ROTEM parameters in differentiating of NEC from sepsis at the disease onset. Neonates with NEC present acceleration of coagulation and exhibit a hypercoagulable profile, as this is expressed by ROTEM parameters, in comparison to septic and healthy neonates. ROTEM parameters demonstrated a good diagnostic capacity in differentiating NEC from sepsis at the disease onset.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | - Petros Mantzios
- Department of Internal Medicine, General Hospital of Eastern Achaia, Aigio, Greece
| | - Andreas G Tsantes
- Microbiology Department, "Saint Savvas" Oncology Hospital, Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Georgios Ioakeimidis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Maria Lampridou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Styliani Kokoris
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis G Vaiopoulos
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Elsayed Y, Louis D, Hinton M, Seshia M, Alvaro R, Dakshinamurti S. A Novel Integrated Clinical-Biochemical-Radiological and Sonographic Classification of Necrotizing Enterocolitis. Am J Perinatol 2024; 41:e3401-e3412. [PMID: 38211608 DOI: 10.1055/s-0043-1778666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To evaluate the sensitivity and specificity of clinical, laboratory, and radiological markers and the neonatologist-performed intestinal ultrasound (NP-IUS) for treatment interventions in preterm neonates who developed necrotizing enterocolitis (NEC). STUDY DESIGN This was a case-control study of preterm neonates < 35 weeks with a diagnostic workup for NEC. The diagnostic workup included NP-IUS performed by trained neonatologists using a standard protocol, abdominal roentgenogram (AXR), and laboratory investigations. Intestinal ultrasound (IUS) performed by two neonatologists was standardized to detect 11 injury markers. AXRs were read independently by experienced pediatric radiologists. The investigators who retrospectively interpreted the IUS were blinded to the clinical and treatment outcomes. RESULTS A total of 111 neonates were assessed. Fifty-four did not require intervention and formed the control group. Twenty cases were treated medically, 21 cases were treated with late surgery for stricture or adhesions, and 16 were treated with early surgery. The integrated model of cumulative severity of ultrasound markers, respiratory and hemodynamic instability, abdominal wall cellulitis, and C- reactive protein > 16 mg/L had an area under the curve (AUC) of 0.89 (95% confidence interval [CI]: 0.83-0.94%, p < 0.0001) for diagnosing NEC requiring surgical intervention. We also investigated the utility of Bell's classification to diagnose either the need for surgery or death, and it had an AUC of 0.74 (95% CI: 0.65-0.83%, p < 0.0001). CONCLUSION In this cohort, a combination of specific IUS markers and clinical signs of instability, abdominal wall cellulitis, plus laboratory markers were diagnostic of NEC requiring interventions. KEY POINTS · The diagnosis of necrotizing enterocolitis requires a combination of markers.. · The combination of specific ultrasound markers, clinical signs, and laboratory markers were diagnostic of NEC requiring intervention.. · The intestinal ultrasound performed by a trained neonatologist was the most sensitive diagnostic marker of NEC requiring surgical intervention..
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Affiliation(s)
- Yasser Elsayed
- Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deepak Louis
- Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martha Hinton
- Department of Pediatrics, Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
| | - Mary Seshia
- Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruben Alvaro
- Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shyamala Dakshinamurti
- Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics, Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
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Garg PP, Riddick R, Ansari MAY, Pittman I, Ladd MR, Porcelli P, Garg PM. Risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis and associated outcomes. J Neonatal Perinatal Med 2024; 17:77-89. [PMID: 38217616 PMCID: PMC10939752 DOI: 10.3233/npm-230076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
BACKGROUND We aim to determine clinical risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). METHODS A retrospective cohort study of preterm infants with surgical NEC or SIP to compare clinical factors between those with and without postoperative complications. RESULTS 78/109 (71.5%) infants had any complication following surgical NEC. Adhesions (20/35, 57.1%) and wound infection (6/35, 17.1%) were the most common single surgical complications. Patients with a single surgical complication (35/66, 53%) were significantly less likely to be exposed to antenatal steroids, more frequently had a jejunostomy, needed a central line longer, and had a longer length of stay than those without any surgical complication. Infants with > 1 surgical complication (43/71, 60.5%) included mainly females, and had AKI more frequently at NEC onset, lower weight z-scores and lower weight for length z- scores at 36 weeks PMA than those without any complications.On multinomial logistic regression, antenatal steroids exposure (OR 0.23 [CI 0.06, 0.84]; p = 0.027) was independently associated with lower risk and jejunostomy 4.81 (1.29, 17.9) was independently associated with higher risk of developing a single complication. AKI following disease onset (OR 5.33 (1.38, 20.6), P = 0.015) was independently associated with > 1 complication in surgical NEC/SIP infants. CONCLUSION Infants with postoperative complications following surgical NEC were more likely to be female, have additional morbidities, and demonstrate growth failure at 36 weeks PMA than those without surgical complications. There was no difference in mortality between those with and without surgical complications.
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Affiliation(s)
- P P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - R Riddick
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - M A Y Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - I Pittman
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - M R Ladd
- Department of General Surgery/Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - P Porcelli
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - P M Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
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Culbreath K, Keefe G, Nes E, Edwards EM, Knell J, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Association between neurodevelopmental outcomes and concomitant presence of NEC and IVH in extremely low birth weight infants. J Perinatol 2024; 44:108-115. [PMID: 37735208 DOI: 10.1038/s41372-023-01780-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To quantify the association between necrotizing enterocolitis (NEC) and neurodevelopmental disability (NDI) in extremely low birth weight (ELBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN ELBW survivors born 2011-2017 and evaluated at 16-26 months corrected age in the Vermont Oxford Network (VON) ELBW Follow-Up Project were included. Logistic regression determined the adjusted relative risk (aRR) of severe NDI in medical or surgical NEC compared to no NEC, stratified by severity of IVH. RESULTS Follow-up evaluation occurred in 5870 ELBW survivors. Compared to no NEC, medical NEC had no impact on NDI, regardless of IVH status. Surgical NEC increased risk of NDI in patients with no IVH (aRR 1.69; 95% CI 1.36-2.09), mild IVH (aRR 1.36;0.97-1.92), and severe IVH (aRR 1.35;1.13-1.60). CONCLUSIONS ELBW infants with surgical NEC carry increased risk of neurodevelopmental disability within each IVH severity stratum. These data describe the additive insult of surgical NEC and IVH on neurodevelopment, informing prognostic discussions and highlighting the need for preventative interventions.
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Affiliation(s)
- Katherine Culbreath
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | - Gregory Keefe
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | - Emily Nes
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | - Jamie Knell
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | | | - Tom Jaksic
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | - Biren P Modi
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA.
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Garg PM, Pittman I, Taylor C, Reddy K, Varshney N, Hillegass WB, Shetty A, Yi J, Inder T, Garg P. Clinical Correlates of Cerebellar Injury in Preterm Infants with Surgical Necrotizing Enterocolitis. RESEARCH SQUARE 2023:rs.3.rs-3720723. [PMID: 38168331 PMCID: PMC10760219 DOI: 10.21203/rs.3.rs-3720723/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Objective Determine the risk factors of cerebellar injury in infants with surgical necrotizing enterocolitis (NEC). Methods Retrospective study compared clinical/pathological information between surgical NEC infants with and those without cerebellar injury. Results Infants with cerebellar injury (21/65, 32.3%) had significantly more hemorrhagic and the reparative lesions on the intestinal histopathology, had patent ductus arteriosus (PDA) more often, received red cell transfusion frequently, had blood culture positive sepsis and grew gram positive organisms more often and had cholestasis frequently following NEC than those without cerebellar injury. On multilogistic regression, the positive blood culture sepsis (OR 3.9, CI 1.1-13.7, p = 0.03), PDA (OR 4.5, CI 1.0-19.9, p = 0.04) and severe hemorrhage (grade 3-4)(OR 16.9, CI 2.1-135.5, p = 0.007) were independently associated with higher risk of cerebellar injury. Conclusion The cerebellar injury was most likely associated with positive blood culture sepsis following NEC, PDA, and severe hemorrhage lesions (grade 3-4) in infants with surgical NEC.
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Affiliation(s)
| | | | | | | | | | | | | | - Joe Yi
- 3. Frank Porter Graham Child Development Institute, University of North Carolina
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Gómez-Ferrer M, Amaro-Prellezo E, Albiach-Delgado A, Ten-Domenech I, Kuligowski J, Sepúlveda P. Identification of omega-3 oxylipins in human milk-derived extracellular vesicles with pro-resolutive actions in gastrointestinal inflammation. Front Immunol 2023; 14:1293737. [PMID: 38054009 PMCID: PMC10694275 DOI: 10.3389/fimmu.2023.1293737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 12/07/2023] Open
Abstract
Introduction Premature infants (PIs) are at risk of suffering necrotizing enterocolitis (NEC), and infants consuming human milk (HM) show a lower incidence than infants receiving formula. The composition of HM has been studied in depth, but the lipid content of HM-derived small extracellular vesicles (HM sEVs) remains unexplored. Identifying these molecules and their biological effects has potential for the treatment of intestinal disorders in PIs and could contribute to the development of HM-based fortified formulas. Methods We isolated HM sEVs from HM samples and analyzed their oxylipin content using liquid chromatography coupled to mass spectrometry, which revealed the presence of anti-inflammatory oxylipins. We then examined the efficacy of a mixture of these oxylipins in combating inflammation and fibrosis, in vitro and in a murine model of inflammatory bowel disease (IBD). Results HM-related sEVs contained higher concentrations of oxylipins derived from docosahexaenoic acid, an omega-3 fatty acid. Three anti-inflammatory oxylipins, 14-HDHA, 17-HDHA, and 19,20-DiHDPA (ω3 OXLP), demonstrated similar efficacy to HM sEVs in preventing cell injury, inducing re-epithelialization, mitigating fibrosis, and modulating immune responses. Both ω3 OXLP and HM sEVs effectively reduced inflammation in IBD-model mice, preventing colon shortening, infiltration of inflammatory cells and tissue fibrosis. Discussion Incorporating this unique cocktail of oxylipins into fortified milk formulas might reduce the risk of NEC in PIs and also provide immunological and neurodevelopmental support.
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Affiliation(s)
- Marta Gómez-Ferrer
- Regenerative Medicine and Heart Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Elena Amaro-Prellezo
- Regenerative Medicine and Heart Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Abel Albiach-Delgado
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Isabel Ten-Domenech
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute Hospital La Fe, Valencia, Spain
| | - Pilar Sepúlveda
- Regenerative Medicine and Heart Transplantation Unit, Health Research Institute Hospital La Fe, Valencia, Spain
- Cardiology Service, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Carlos III Institute of Health, Madrid, Spain
- Department of Pathology, University of Valencia, Valencia, Spain
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Everhart KC, Iskersky VN, Donevant SB, Wirth MD, Dail RB. Pathogenesis of Necrotizing Enterocolitis in Preterm Infants: An Adaptation of Neuman's Systems Theory. Nurs Sci Q 2023; 36:152-157. [PMID: 36994958 DOI: 10.1177/08943184221150264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Preterm infants have increased morbidity and mortality due to immature physiology and neonatal complications. Necrotizing enterocolitis (NEC) is a devastating gastrointestinal complication that affects morbidity and mortality in preterm infants. The authors present an adaptation of Neuman's systems model called the NEC systems model to explore intrinsic and extrinsic factors leading to NEC in preterm infants. The literature was searched for theoretical models to guide exploration of neonatal disease influenced by the environment. Neuman's Systems Model provides a holistic approach to care of the system, offering a foundation to develop frameworks to examine preterm infants in their environment with associated stressors.
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Affiliation(s)
- Kayla C Everhart
- Doctoral Student and Research Coordinator, University of South Carolina-College of Nursing, Columbia, South Carolina, USA
| | - Victor N Iskersky
- Director of Neonatology Prisma Health Midlands, Medical Director Prisma Health Richland, Neonatal Intensive Care Unit, Clinical Associate Professor of Pediatrics, School of Medicine University of South Carolina, Columbia, South Carolina, USA
| | - Sara B Donevant
- Assistant Professor, University of South Carolina-College of Nursing, Columbia, South Carolina, USA
| | - Michael D Wirth
- Assistant Professor, College of Nursing and Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Robin B Dail
- Associate Dean for Faculty Affairs and Professor, University of South Carolina-College of Nursing, Columbia, South Carolina, USA
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Garg PM, Paschal JL, Ansari MAY, Ware J, Adams K, Taylor C, Reddy K, Rosenfeld CR, Mir IN. Correlation of placental pathology with the postoperative outcomes and white matter injury in preterm infants following necrotizing enterocolitis. J Neonatal Perinatal Med 2023; 16:93-103. [PMID: 36744350 DOI: 10.3233/npm-221105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To determine the association of placental pathologic lesions with postoperative outcomes, survival, and white matter injury (WMI) in preterm infants with NEC. METHODS A retrospective chart review of 107 neonates with NEC (Bell stage > IIa) from Jan 2013- June 2020 was completed. Demographic, clinical, and outcome data were compared between infants with or without placental pathologic lesions. RESULTS In this cohort, 59/107 (55%) infants had medical NEC, and 48 (45%) had surgical NEC. The infants had a mean gestational age of 28.1±3.7 weeks and a birth weight of 1103±647 g. Maternal vascular malperfusion (82/107, 76.6%) and acute histological chorioamnionitis (42, 39.3%) were the most common pathological placental lesions. Acute histologic chorioamnionitis with fetal inflammatory response was more common in infants with surgical NEC vs. medical NEC (35.4% vs. 15.3%; p = 0.02). The NEC Infants with WMI on brain MRI scans had a significantly higher incidence of acute histological chorioamnionitis (52% vs. 27.8%; P = 0.04). No significant differences in mortality, length of stay and postoperative outcomes in neonates with and without acute histologic chorioamnionitis with fetal inflammatory response were noted. On unadjusted logistic regression, acute histologic chorioamnionitis without fetal inflammatory response was also associated with higher odds of WMI (OR 2.81; 95% CI 1.05-7.54; p = 0.039). CONCLUSION Acute histological chorioamnionitis without fetal inflammatory response was associated with higher odds of WMI in infants with NEC, with no significant impact on mortality and other postoperative outcomes.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - J L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - M A Y Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - J Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - K Adams
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - C Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - K Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - C R Rosenfeld
- Department of Pediatrics/Neonatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - I N Mir
- Department of Pediatrics/Neonatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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11
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Garg PM, Rebentisch A, Zhang M, Ware J, Pippins M, Taylor C, Reddy K, Lewis T, Inder TE, Hillegass WB. Clinical impact of analgesic-sedative agents and peri-operative clinical status on white matter brain injury in preterm infants following surgical NEC. J Neonatal Perinatal Med 2023; 16:527-537. [PMID: 37742664 PMCID: PMC10615724 DOI: 10.3233/npm-230084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND The potential influence of exposure to analgesic-sedative agents (ASA) before, during, and after surgical NEC and peri-operative clinical status on white matter injury (WMI) in preterm infants has not been fully defined, and a comprehensive evaluation may inform future research and clinical interventions. METHODS A retrospective study comparing ASA exposure before/during /after surgical NEC and peri-operative clinical status in neonates with and without WMI. RESULTS Infants with any WMI (grade 2-4, n = 36/67, 53.7%) had a higher number of surgical procedures receiving ASA (5 [IQR: 3, 8] vs. 3 [2, 4]; p = 0.002) and had a longer duration of hypotension during their first (48.0 hours [26.0, 48.0] vs. 15.5 [6, 48]; p = 0.009) and second surgery (20 hours [0, 48h] vs. 0 [0, 22]; p = 0.017), received more hydrocortisone (35% vs.13.3%,p = 0.04) than those without any WMI. There were no differences in fentanyl/morphine/midazolam exposure before/during/after the NEC onset in the two groups.Infants with severe WMI (19/67, 28.3%, grade 3/4) had a higher incidence of AKI (P = 0.004), surgical morbidity (p = 0.047), more surgical procedures (6.5 [3, 10] vs. 4 [2, 5]; p = 0.012), and received higher mean fentanyl doses(p = 0.03) from birth until NEC onset than those without severe WMI. The univariate associations between these factors and severe WMI remained insignificant after multivariable logistic regression. CONCLUSION Infants with WMI had more surgical procedures receiving ASA and had a longer duration of hypotension during surgeries. A large multicenter prospective study is needed to understand the full impact of ASA.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - A Rebentisch
- Department of Neonatal Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - M Zhang
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - J Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - M Pippins
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - C Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - K Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - T Lewis
- The Hospital for Sick Children, Divisions of Clinical Pharmacology & Neonatology, Toronto, ON, Canada
| | - T E Inder
- Children Hospital of Orange County, University of California, Irvine, Orange, CA, USA
| | - W B Hillegass
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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12
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Culbreath K, Knell J, Keefe G, Nes E, Han SM, Edwards EM, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Impact of concomitant necrotizing enterocolitis on mortality in very low birth weight infants with intraventricular hemorrhage. J Perinatol 2023; 43:91-96. [PMID: 35715599 DOI: 10.1038/s41372-022-01434-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/02/2022] [Accepted: 06/09/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the impact of necrotizing enterocolitis (NEC) on mortality in very low birth weight (VLBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN Data were collected on VLBW infants born 2014-2018 at Vermont Oxford Network (VON) centers. NEC and IVH were categorized by severity. Adjusted risk ratios (ARR) for in-hospital mortality were calculated. RESULTS This study included 187 187 VLBW infants. Both medical and surgical NEC increased mortality risk compared to those without NEC. Stratification by IVH severity modified this effect (no IVH: ARR 3.04 (95%CI 2.74-3.38) for medical NEC and 4.17 (3.84-4.52) for surgical NEC; mild IVH: ARR 2.14 (1.88-2.44) for medical NEC and 2.49 (2.24-2.78) for surgical NEC; severe IVH: ARR 1.14 (1.03-1.26) for medical NEC and 1.10 (1.02-1.18) for surgical NEC). CONCLUSION The relative impact of NEC on mortality decreased as IVH severity increased. Given the frequent coexistence of NEC and IVH, these data inform multidisciplinary management of these complex patients.
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Affiliation(s)
- Katherine Culbreath
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jamie Knell
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gregory Keefe
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Emily Nes
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sam M Han
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Tom Jaksic
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Biren P Modi
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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13
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Garg PM, Paschal JL, Ansari MAY, Sonani H, Grey C, Chan S, Varshney N, Hillegass W. Clinical outcomes and gestational age based prediction of pneumatosis intestinalis in preterm infants with necrotizing enterocolitis. J Neonatal Perinatal Med 2022; 15:803-812. [PMID: 35811540 DOI: 10.3233/npm-210971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND To determine the clinical implications and gestation age-specific diagnostic predictability of pneumatosis in preterm infants with necrotizing enterocolitis (NEC). METHODS A retrospective study on abdominal radiographs comparing clinical and radiological information in infants with and without pneumatosis. RESULT Our findings disproved our hypothesis. Pneumatosis was seen more frequently in infants with higher gestational age [28.4 (26.1-32.4) vs. 26.4 (24.3-29) weeks; p < 0.001] and birth weight [1110 (762-1768) vs. 770 (645-1022) grams; p < 0.001] and were more likely delivered vaginally (39.1% vs. 21.7%, p = 0.01). Portal venous gas was seen frequently on radiographs (10.3% vs. 0%, p < 0.001), but not pneumoperitoneum (20.7% vs. 36.7%, p = 0.02). Infants with pneumatosis frequently developed acute kidney injury, with higher serum creatinine (16.5% vs. 4.5%, p = 0.02) and frequent oliguria (12.9% vs. 2.7 %; p = 0.043) and had higher C-reactive protein levels at 24 and 96 hours (p < 0.002). Receiver operating curves for pneumatosis showed GA >28 weeks and birth weight > 1000 gm to have a sensitivity of 58.6% and specificity of 72.5%. CONCLUSION Contrary to our hypothesis, infants who developed pneumatosis during NEC were more mature with a higher gestational age and birth weight than those who did not.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, University of Mississippi, Jackson, MS, USA
| | - J L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi, Jackson, MS, USA
| | - M A Y Ansari
- Department of Data Science, University of Mississippi, Jackson, MS, USA
| | - H Sonani
- Departments of Pathology, University of Mississippi, Jackson, MS, USA
| | - C Grey
- Departments of Pathology, University of Mississippi, Jackson, MS, USA
| | - S Chan
- Departments of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - N Varshney
- Departments of Pathology, University of Mississippi, Jackson, MS, USA
| | - W Hillegass
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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14
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Garg PM, Denton MX, Talluri R, Ostrander MM, Middleton C, Sonani H, Varshney N, Hillegass WB. Clinical determinants and impact of hemorrhagic lesions on intestinal pathology in preterm infants with surgical necrotizing enterocolitis. J Neonatal Perinatal Med 2022; 16:119-128. [PMID: 36565070 DOI: 10.3233/npm-221116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We sought to determine the clinical and histopathological factors associated with intestinal hemorrhage and its correlation with clinical outcomes in neonates with surgical necrotizing enterocolitis (NEC). METHODS A retrospective study compared clinical and histopathology information in neonates following surgical NEC with severe hemorrhage and those with mild/moderate hemorrhagic lesions seen on resected intestine pathology. RESULTS The infants with severe hemorrhage (Grade 3-4, 81/148, 54.7%) had significantly lower exposure to antenatal steroids (52.5 % vs 76.9 % ; p = 0.004), had higher gestational age (28.5 weeks [7.14] vs. 26.58 [2.90]; p = 0.034), lost more bowel length (p = 0.045), had higher CRP levels at 2 weeks (p = 0.035), and had less intestinal failure ([30.3 % vs 52.5 %]; p = 0.014) than mild/moderate (Grade 0-2, 67/148, 45.2%) hemorrhage group. Those with severe hemorrhage had significantly higher mean inflammation score (2.67 [0.94] vs. 1.63 [0.92]; p = <0.001), higher necrosis scores (1.95 [1.28] vs. 1.49 [1.35]; p = 0.037), higher neovascularization (p = 0.01), higher fibroblasts (p = 0.023) and higher lymphocyte percentages up to 48 hours (p < 0.05) following NEC than mild/ moderate hemorrhage group.On multivariable regression, less exposure to antenatal steroids (OR 0.18 [95% CI 0.05-0.58]; p = 0.005), higher inflammation (OR 3.7 [95% CI 2.09-7.32]; p = 0.001), and lymphocyte count on the day of onset/24 hours following NEC (OR 1.06 [95% CI 1.02-1.11]; p = 0.005) were independently associated with a higher odd of severe intestinal hemorrhage. CONCLUSION The surgical NEC infants with intestinal hemorrhage were less likely to have antenatal steroid exposure but had higher inflammation grade and lymphocyte counts following NEC onset on multivariable regression modeling.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - M X Denton
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - R Talluri
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi
| | - M M Ostrander
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - C Middleton
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - H Sonani
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - N Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
| | - W B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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15
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Garg PM, Paschal JL, Ware J, Hobart HL, O'Connor A, Ansari MAY. Gestational age-specific hematological patterns in preterm infants following necrotizing enterocolitis. J Matern Fetal Neonatal Med 2022; 35:10093-10102. [PMID: 36062737 PMCID: PMC9704046 DOI: 10.1080/14767058.2022.2115885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/28/2022] [Accepted: 07/12/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To investigate gestational age (GA) specific hematological and transfusion response patterns in preterm infants following necrotizing enterocolitis (NEC). DESIGN A retrospective study comparing hematological/transfusion information in three GA groups' infants: Group A ≤ 28 weeks. Group B 28-32 weeks, Group C > 32 weeks following necrotizing enterocolitis. RESULTS Group A infants responded with significantly higher WBC count, thrombocytopenia, higher absolute neutrophil, and higher absolute monocyte and lower absolute lymphocyte counts following NEC onset, received more blood transfusions before NEC onset (59.8 versus 30.0%; p = .007), and had higher odds of surgical NEC (OR 3.39 [95% CI 1.19-10.38]; p = .02) than group C. One unit increase in absolute lymphocyte count on the day, and 24 h following NEC was significantly associated with lower surgical NEC odds than groups C. CONCLUSION The infant's in-group A had significantly different hematological response patterns following NEC than infants with higher gestational age (groups B and C).
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Jennifer Ware
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Haley L Hobart
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Anna O'Connor
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MI, USA
| | - Md Abu Yusuf Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, MI, USA
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16
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Garg PM, Paschal JL, Ansari MAY, Block D, Inagaki K, Weitkamp JH. Clinical impact of NEC-associated sepsis on outcomes in preterm infants. Pediatr Res 2022; 92:1705-1715. [PMID: 35352003 DOI: 10.1038/s41390-022-02034-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine risk factors and outcomes of necrotizing enterocolitis (NEC)-associated sepsis in infants with NEC. METHODS A retrospective review comparing demographic and clinical information in infants with and without NEC-associated sepsis (defined as positive blood culture at the time of NEC onset). RESULTS A total of 209 infants with medical (n = 98) and surgical NEC (n = 111) had a median gestational age of 27 weeks (IQR 25; 30.5) and a median birth weight of 910 g [IQR 655; 1138]. Fifty of 209 (23.9%) infants had NEC-associated sepsis. Infants with NEC-associated sepsis had lower median GA (26.4 vs. 27.4 weeks; p = 0.01), lower birth weight (745 vs. 930 g; p = 0.009), were more likely mechanically ventilated [p < 0.001], received dopamine [p < 0.001], had more evidence of acute kidney injury [60% vs. 38.4%, p = 0.01], longer postoperative ileus (16 [13.0; 22.0] vs. 12 [8; 16] days; p = 0.006), higher levels of C-reactive protein, lower platelet counts, longer hospitalization compared to infants without NEC-associated sepsis. On multivariate regression, cholestasis was an independent risk factor for NEC-associated sepsis (OR 2.94; 95% CI 1.1-8.8, p = 0.038). CONCLUSION NEC-associated sepsis was associated with greater hemodynamic support, acute kidney injury, longer postoperative ileus, and hospitalization on bivariate analysis, and cholestasis was associated with higher odds of sepsis on multi regression analysis. IMPACT NEC-associated sepsis was present in 24% of infants with NEC. Gram-positive bacteria, Gram-negative bacteria, and Candida were found in 15.3%, 10.5%, and 2.8% of cases, respectively. Infants with NEC-associated sepsis had a greater inflammatory response (CRP levels), received more blood transfusion before NEC onset, frequently needed assisted ventilation ionotropic support, and had acute kidney injury after NEC onset. NEC infants with Gram-negative sepsis had higher portal venous gas, received more platelet transfusions before NEC onset, and had higher CRP levels and lower median lymphocyte counts at 24 h after NEC onset than those with Gram-positive sepsis.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Danielle Block
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kengo Inagaki
- Department of Pediatrics/Infectious Disease, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics/Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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17
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Garg PM, Paschal JL, Zhang M, Pippins M, Taylor C, Sanderson K, Reddy K, Askenazi D, Padbury JF, Hillegass WB. Clinical impact of severe acute kidney injury on post-operative and brain injury outcomes in preterm infants following surgical necrotizing enterocolitis. J Matern Fetal Neonatal Med 2022; 35:10124-10136. [PMID: 36093832 PMCID: PMC10986639 DOI: 10.1080/14767058.2022.2121917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/24/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND To evaluate post-operative outcomes and white matter injury (WMI) using brain MRI at term equivalent in neonates with and without severe acute kidney injury (AKI) following surgical necrotizing enterocolitis (NEC). METHODS A retrospective cohort study comparing neonates with severe (Stage 2/3) vs. other (no AKI/Stage 1) AKI using KDIGO classification with multivariable models assessing this association in the context of multiple systemic comorbidities. RESULTS Of 103 neonates with surgical NEC, 60 (58%) had severe AKI. Those with severe AKI had lower birth weight (BW; 715 vs. 950 g; p = .023), more frequently treated with indomethacin (18.3 vs. 2.4%); p = .014), higher CRP levels at 24 h after NEC onset (14.4 [6.4-19.8] vs. 4.8 [1.6-13.4]; p = .005), higher presence of cholestasis (73.3 vs. 51.2%); p = .023), later age of NEC onset (14 vs. 7 d); p = .004), longer length of bowel resected (14.9 vs. 4.3 cm); p = .011), longer post-operative ileus days (14 vs. 9 d); p < .001), longer post-operative days at starting enteral feedings (15 vs. 10 d; p < .001), longer days of attainment of full enteral feedings (75 vs. 44.5 d; p = .008) and longer length of stay (140.5 vs. 94 d; p = .028) compared to those without severe AKI. Compared to infants without AKI by serum creatinine, those with AKI had significantly more cases of white matter abnormality (WMA; 90 vs. 36.6%; p < .001) and retinopathy of prematurity (63.9 vs. 35.3%; p = .017). In addition, the presence of AKI Stage 2 and 3 by serum creatinine was independently associated with higher odds of sustaining severe WMI level on an ordinal scale (OR = 6.2; 95% CI = (1.1-35.5); p = .041). CONCLUSIONS Neonates with severe AKI following surgical NEC were more likely to experience longer post-operative morbidity and higher WMI by MRI at term.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mengna Zhang
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Melissa Pippins
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlotte Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Keia Sanderson
- Department of Medicine, UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kartik Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - David Askenazi
- Department of Pediatrics/Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James F Padbury
- Department of Pediatrics, Davis School of Medicine, University of California, Sacramento, CA, USA
| | - William B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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18
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Culbreath K, Keefe G, Edwards EM, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Morbidity associated with laparotomy-confirmed spontaneous intestinal perforation: A prospective multicenter analysis. J Pediatr Surg 2022; 57:981-985. [PMID: 35287964 DOI: 10.1016/j.jpedsurg.2022.01.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Differences in morbidities between spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are unknown. METHODS Prospectively collected multicenter data regarding very low birth weight (VLBW) infants 2015-2019 were analyzed. Diagnosis of SIP or NEC was laparotomy-confirmed in all patients. Multivariable regression modeling was used to assess adjusted length of stay (LOS; primary outcome) and adjusted risk ratios (ARR) for weight <10th percentile at discharge, and supplemental oxygen requirement at discharge. RESULTS Of 201,300 VLBW infants at 790 hospitals, 1523 had SIP and 2601 had NEC. Adjusted LOS was similar for SIP and NEC (92 vs 88 days, p = 0.08561), but significantly higher than seen without SIP or NEC (68 days, p<0.0001). The risk of growth morbidity at discharge was similar between SIP and NEC (74.2% vs 75.3%; ARR:1.00;0.94,1.06), but higher than infants without SIP or NEC (47.7%; ARR:0.50;0.47,0.53). Infants with NEC were less likely to require supplemental oxygen at discharge than infants with SIP (24.4% vs 34.9%; ARR:0.80; 0.71,0.89). CONCLUSIONS Although mortality is known to be lower in VLBW infants with SIP than NEC, this study highlights the similarly high morbidity experienced by both groups of infants. These benchmark data can help align counseling of families with expected outcomes. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Prognosis study (Cohort Study).
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Affiliation(s)
- Katherine Culbreath
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA
| | - Gregory Keefe
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA
| | | | | | | | - Tom Jaksic
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA
| | | | - Biren P Modi
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.
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19
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Prediction of High Bell Stages of Necrotizing Enterocolitis Using a Mathematic Formula for Risk Determination. CHILDREN 2022; 9:children9050604. [PMID: 35626781 PMCID: PMC9139239 DOI: 10.3390/children9050604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/23/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Necrotizing enterocolitis (NEC) continues to cause high morbidity and mortality. Identifying early predictors for severe NEC is essential to improve therapy and optimize timing for surgical intervention. We present a retrospective study of patients with NEC, treated between 2010 and 2020, trying to identify factors influencing the severity of NEC. Within the study period, 88 affected infants with NEC or NEC-like symptoms are analyzed. A multiple logistic regression analysis reveals the following three independent predictors for NEC in Bell stage III: red blood cell transfusion (p = 0.027 with odds ratio (OR) = 3.298), sonographic findings (p = 0.037; OR = 6.496 for patients with positive vs. patients without pathological findings) and cardiac anatomy (p = 0.015; OR = 1.922 for patients with patent ductus arteriosus (PDA) vs. patients with congenital heart disease (CHD); OR = 5.478/OR = 2.850 for patients with CHD/PDA vs. patients without cardiac disease). Results are summarized in a clinical score for daily application in clinical routine. The score is easy to apply and combines clinically established parameters, helping to determine the timing of surgical intervention.
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20
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Kaelin EA, Rodriguez C, Hall-Moore C, Hoffmann JA, Linneman LA, Ndao IM, Warner BB, Tarr PI, Holtz LR, Lim ES. Longitudinal gut virome analysis identifies specific viral signatures that precede necrotizing enterocolitis onset in preterm infants. Nat Microbiol 2022; 7:653-662. [PMID: 35449461 PMCID: PMC9064801 DOI: 10.1038/s41564-022-01096-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/02/2022] [Indexed: 12/22/2022]
Abstract
Necrotizing enterocolitis (NEC) is a serious consequence of preterm birth and is often associated with gut bacterial microbiome alterations. However, little is known about the development of the gut virome in preterm infants, or its role in NEC. Here, using metagenomic sequencing, we characterized the DNA gut virome of 9 preterm infants who developed NEC and 14 gestational age-matched preterm infants who did not. Infants were sampled longitudinally before NEC onset over the first 11 weeks of life. We observed substantial interindividual variation in the gut virome between unrelated preterm infants, while intraindividual variation over time was significantly less. We identified viral and bacterial signatures in the gut that preceded NEC onset. Specifically, we observed a convergence towards reduced viral beta diversity over the 10 d before NEC onset, which was driven by specific viral signatures and accompanied by specific viral-bacterial interactions. Our results indicate that bacterial and viral perturbations precede the sudden onset of NEC. These findings suggest that early life virome signatures in preterm infants may be implicated in NEC.
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Affiliation(s)
- Emily A Kaelin
- School of Life Sciences, Arizona State University, Tempe, AZ, USA.,Center for Fundamental and Applied Microbiomics, Biodesign Institute, Arizona State University, Tempe, AZ, USA
| | - Cynthia Rodriguez
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Carla Hall-Moore
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Julie A Hoffmann
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Laura A Linneman
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - I Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Barbara B Warner
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Phillip I Tarr
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA.,Department of Molecular Microbiology, Washington University School of Medicine, St Louis, MO, USA
| | - Lori R Holtz
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA.
| | - Efrem S Lim
- School of Life Sciences, Arizona State University, Tempe, AZ, USA. .,Center for Fundamental and Applied Microbiomics, Biodesign Institute, Arizona State University, Tempe, AZ, USA.
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21
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Diez S, Renner M, Bahlinger V, Hartmann A, Besendörfer M, Müller H. Increased expression of OLFM4 and lysozyme during necrotizing enterocolitis in neonates: an observational research study. BMC Pediatr 2022; 22:192. [PMID: 35410162 PMCID: PMC8996401 DOI: 10.1186/s12887-022-03260-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/31/2022] [Indexed: 01/05/2023] Open
Abstract
Background In neonatal patients with necrotizing enterocolitis (NEC) the inflammatory response is mediated by a plurality of different proteins. The proteins olfactomedin 4 (OLFM4) and lysozyme (LYZ) are part of the intestinal mucosal defense and especially OLFM4 has rarely been evaluated in neonatal gastrointestinal diseases. The aim of this study was to analyze whether expression levels of both proteins of innate immunity, OLFM4 and lysozyme, were increased during NEC in neonates. Methods Intestinal tissues of patients with NEC were examined with immunohistochemical staining of formalin-fixed and paraffin-embedded sections of resected tissue using antibodies against OLFM4 and lysozyme. Staining-positive tissues were semi-quantitatively scored from 0 (no staining), 1 (weak staining), 2 (moderate staining) to 3 (highly intense staining) by two individual investigators. Intestinal tissue of infants with volvulus was used as a control as other intestinal tissue without major inflammation was not available. Results Both applied antibodies against OLFM4 showed different staining patterns with higher staining intensity of the antibody OLFM4 (D1E4M). OLFM4 (median score of the antibody OLFM4 (D1E4M): 3.0) and lysozyme (median score: 3.0) are highly expressed in intestinal and immune cells during NEC. Expression of OLFM4 and lysozyme in the control samples with volvulus was observable but significantly lower (median score of the antibody OLFM4 (D1E4M): 1.25; median score of the antibody against LYZ: 2.0; p = 0.033 and p = 0.037, respectively). Conclusions Both proteins, OLFM4 and lysozyme, may play a role in the pathogenesis of NEC in neonatal patients, but the exact mechanisms of OLFM4 and lysozyme function and their role in immunological responses have not yet been resolved in detail. These observations add new insights as basis for further large-scale population research.
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Affiliation(s)
- Sonja Diez
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Pediatric Surgery, Department for General Surgery, University Hospital Erlangen, Loschgestraße 15, 91054, Erlangen, Germany.
| | - Marcus Renner
- Institute of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Veronika Bahlinger
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Manuel Besendörfer
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Pediatric Surgery, Department for General Surgery, University Hospital Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Department of Pediatrics, University of Marburg, Baldingerstraße, 35033, Marburg, Germany
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22
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Hwang M, Tierradentro-García LO, Dennis RA, Anupindi SA. The role of ultrasound in necrotizing enterocolitis. Pediatr Radiol 2022; 52:702-715. [PMID: 34654968 DOI: 10.1007/s00247-021-05187-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/07/2021] [Accepted: 08/12/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Luis O Tierradentro-García
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rebecca A Dennis
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sudha A Anupindi
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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23
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Brain injury in preterm infants with surgical necrotizing enterocolitis: clinical and bowel pathological correlates. Pediatr Res 2022; 91:1182-1195. [PMID: 34103675 DOI: 10.1038/s41390-021-01614-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to determine the risk factors and outcomes of white matter brain injury (WMBI) on magnetic resonance imaging (MRI) at term-equivalent age in infants with surgical necrotizing enterocolitis (NEC). METHODS This retrospective study compared clinical/pathological information between infants with and those without WMBI. RESULTS Out of 69 infants with surgical NEC, 17 (24.6%) had mild WMBI, 13 (18.8%) had moderate WMBI, and six (8.7%) had severe WMBI on the brain MRI. Several clinical factors (gestational age, more red blood cell (RBC) transfusions before NEC onset, pneumoperitoneum, earlier NEC onset age, postoperative ileus, acute kidney injury (AKI) by serum creatinine, postnatal steroids, hospital stay) and histopathological findings (necrosis, hemorrhage) had univariate associations with WMBI. Associations with RBC transfusion (odds ratio (OR) 23.6 [95% confidence interval (CI): 4.73-117.97]; p = 0.0001), age at NEC onset (OR 0.30 [95%CI: 0.11-0.84]; p = 0.021), necrosis (OR 0.10 [95%CI: 0.01-0.90]; p = 0.040), and bowel hemorrhage (OR 7.79 [95%CI: 2.19-27.72]; p = 0.002) persisted in multivariable association with grade 3-4 WMBI. The infants with WMBI had lower mean motor, cognitive, language scores, and higher ophthalmic morbidity at 2 years of age. CONCLUSIONS The WMBI was most likely associated with earlier NEC onset, higher RBC transfusions, and less necrosis and greater hemorrhage lesions on intestinal pathology in preterm infants with surgical NEC. IMPACT In preterm infants with surgical NEC, brain MRI showed injury in the white matter in 52%, gray matter in 10%, and cerebellar region in 30%. Preterm infants with severe WMBI (grade 3-4) had less necrosis and greater hemorrhagic lesions on histopathology of the bowel. Preterm infants with WMBI were more likely to have a more severe postoperative course, AKI, and longer length of hospitalization. Neuroprotective strategies to prevent brain injury in preterm infants with surgical NEC are needed with the goal of improving the neurodevelopmental outcomes.
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24
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Garg PM, Paschal JL, Lett K, Middleton C, Varshney N, Maheshwari A. Intestinal Resection is More Likely to be Effective in Necrotizing Enterocolitis Extending to Colon than in Disease Limited to the Small Intestine. NEWBORN 2022; 1:14-26. [PMID: 35846895 PMCID: PMC9282977 DOI: 10.5005/jp-journals-11002-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: The prognosis in surgical necrotizing enterocolitis (NEC) has focused on the total length of the resected bowel; the relative impact of small intestinal vs colonic resection is not well studied. Objective: We hypothesized that intestinal resections may reduce mortality and length of hospital stay (LOS) more likely in infants who have NEC extending into the colon than in those with disease limited to the small intestine. We also investigated the relationship between gestational maturation and NEC-related mortality. Methods: A retrospective study of 153 patients compared demographic, clinical, and histopathological information in infants who had NEC limited to the small intestine vs disease with colonic involvement. Results: Our 153 infants had a mean (±standard deviation) gestational age of 27.4 ± 3.4 weeks and a birth weight of 987 ± 505 g. NEC was limited to the small intestine in 103 (67.3%) infants and extended into the colon in 50 (32.7%). Infants with small intestinal NEC needed shorter bowel resections of 28 ± 31.9 cm than 42.2 ± 40.7 cm in those with colonic involvement (p = 0.02). The LOS was longer in NEC limited to the small intestine than in disease with colonic lesions (96 ± 88.1 vs 69.7 ± 19.1 days; p <0.05). In small intestinal NEC, mortality decreased to <50% beyond a gestational age (GA) >37 weeks. In contrast, infants with NEC that involved the colon had mortality <50% mortality beyond 27.3 weeks’ GA (p = 0.008). Conclusions: Bowel resections may be more likely associated with shorter LOS in surgical NEC that involves both the small bowel and colon, even when longer segments of the gastrointestinal tract are removed, than in disease limited to the small intestine.
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Affiliation(s)
- Parvesh M Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Katherine Lett
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Charles Middleton
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Neha Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Akhil Maheshwari
- Global Newborn Society, Clarksville, Maryland, United States of America
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25
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Neonatal Gastrointestinal Emergencies: A Radiological Review. Arch Pediatr 2022; 29:159-170. [PMID: 35249799 PMCID: PMC8976780 DOI: 10.1016/j.arcped.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/10/2021] [Accepted: 01/30/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Abdominal emergencies in neonates require surgical management in almost all cases and complications may include bowel perforation, sepsis, shock, and even death. Radiological imaging has become a very important aid in the clinical setting as it shortens time to diagnosis. OBJECTIVE The objective of this review is to discuss the more prevalent neonatal gastrointestinal emergencies, review appropriate imaging options, and illustrate common radiological presentations of these entities. CONCLUSION Despite advancements in imaging techniques, it is important to keep in mind that neonates have a higher susceptibility to the adverse effects of ionizing radiation, and therefore radiography and ultrasonography remain the main diagnostic modalities for ruling out the diseases with the worst prognosis. Other modalities (fluoroscopy, computed tomography, and magnetic resonance imaging) may have limited use in very specific conditions. All providers in an emergency department should be familiar with the basic radiological findings that may indicate a gastrointestinal emergency, especially in health institutions that do not have 24-h radiologist coverage.
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26
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Tan X, Zhou Y, Xu L, Zhang L, Wang J, Yang W. The predictors of necrotizing enterocolitis in newborns with low birth weight: A retrospective analysis. Medicine (Baltimore) 2022; 101:e28789. [PMID: 35363166 PMCID: PMC9282129 DOI: 10.1097/md.0000000000028789] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/20/2022] [Indexed: 01/04/2023] Open
Abstract
There are needs to investigate the influencing factors of necrotizing enterocolitis (NEC) in low birth weight (LBW) newborns, to provide insights into the clinical management of NEC.This study was a retrospective cohort study. Infants admitted to our hospital from January 1, 2019 to June 30, 2021 were selected. The clinical characteristics of NEC and no-NEC infants were evaluated. Logistic regression analyses were conducted to assess the risk factors of NEC in LBW infants.A total of 192 LBW infants were included, the incidence of NEC in LBW infants was 35.42%. There were significant differences in the congenital heart disease, sepsis, breastfeeding, blood transfusion and probiotics feeding between NEC and no-NEC group (all P < .05), and there were no significant differences in birth weight, gestational age, mother's pregnancy-induced hypertension, premature rupture of fetal membrane, amniotic fluid pollution, fetal asphyxia, neonatal respiratory distress syndrome and mechanical ventilation between NEC and no-NEC group (all P > .05). Congenital heart disease (OR: 2.128, 95% CI: 1.103-3.511), sepsis (OR: 1.630, 95% CI: 1.022-2.549), and blood transfusion (OR: 1.451, 95% CI: 1.014-2.085) were the independent risk factors for NEC in LBW infants, and breastfeeding (OR: 0.494, 95% CI: 0.023-0.928), probiotics feeding (OR: 0.816, 95% CI: 0.782-0.982) were the protective factors for the NEC in LBW infants. The prognosis of NEC infants undergone surgery treatment was better than that of infants undergone conservative treatments (P = .043).The incidence of NEC in LBW is high, which is affected by many factors, and comprehensive interventions targeted on the risk and protective factors should be made to improve the prognosis of LBW infants.
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Affiliation(s)
- Xuerong Tan
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
- Nursing Department, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Yunxia Zhou
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Lan Xu
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Li Zhang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Jiaying Wang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
| | - Wenqiong Yang
- Department of Neonatology, Ya’an People's Hospital, Ya’an, Sichuan, PR China
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27
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Gill EM, Jung K, Qvist N, Ellebæk MB. Antibiotics in the medical and surgical treatment of necrotizing enterocolitis. A systematic review. BMC Pediatr 2022; 22:66. [PMID: 35086498 PMCID: PMC8793197 DOI: 10.1186/s12887-022-03120-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The aim of this review was to identify relevant randomized controlled trials (RCTs) and non-RCTs to evaluate the existing knowledge on the effect of antibiotic treatment for infants with necrotizing enterocolitis (NEC). OBJECTIVE Identifying 1) the best antibiotic regimen to avoid disease progression as assessed by surgery or death, 2) the best antibiotic regimen for infants operated for NEC as assessed by re-operation or death. METHODS Embase, MEDLINE and Cochrane were searched systematically for human studies using antibiotics for patients with NEC, Bell's stage II and III. RESULTS Five studies were included, with a total of 375 infants. There were 2 RCT and 3 cohort studies. Four main antibiotic regimens appeared. Three with a combination of ampicillin + gentamycin (or similar) with an addition of 1) clindamycin 2) metronidazole or 3) enteral administration of gentamycin. One studied investigated cefotaxime + vancomycin. None of the included studies had a specific regimen for infants undergoing surgery. CONCLUSIONS No sufficient evidence was found for any recommendation on the choice of antibiotics, the route of administration or the duration in infants treated for NEC with Bell's stage II and III.
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Affiliation(s)
- Ester Maria Gill
- Research Unit for Surgery, and Centre of Excellence in Gastrointestinal Diseases and Malformations in Infancy and Childhood (GAIN), Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- University of Southern Denmark, Odense, Denmark.
| | - Kristine Jung
- Research Unit for Surgery, and Centre of Excellence in Gastrointestinal Diseases and Malformations in Infancy and Childhood (GAIN), Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- Research Unit for Surgery, and Centre of Excellence in Gastrointestinal Diseases and Malformations in Infancy and Childhood (GAIN), Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, and Centre of Excellence in Gastrointestinal Diseases and Malformations in Infancy and Childhood (GAIN), Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- University of Southern Denmark, Odense, Denmark
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28
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Han J, Liu G, Yu M, Li G, Cao J, Duan L, Huang L. Analysis of Factors Influencing Outcomes in Preterm Infants With Necrotizing Enterocolitis. Front Pediatr 2022; 10:768107. [PMID: 35633977 PMCID: PMC9136447 DOI: 10.3389/fped.2022.768107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To explore the surgical outcomes between patients with perforated and non-perforated neonatal necrotizing enterocolitis (NEC) and identify indications for surgical intervention. METHODS The surgical outcomes of 271 children with NEC admitted to the Seventh Medical Center of Chinese PLA General Hospital between August 2009 and August 2020 were retrospectively analyzed. The patients were divided into the non-perforated and perforated groups. The preoperative factors, including gestational age, birth weight, intrauterine infection, cholestasis, platelet change, white blood cell count, and C-reactive protein level were compared between the two groups, along with postoperative factors including infection status, complications, enteral and parenteral nutrition time, ICU time, ventilator use time, and intestinal necrosis length. Bell staging was performed for the two groups and the mortality of different Bell stages was explored. The risk of death and predisposing factors of patients with NEC were analyzed. RESULTS In total, 271 children undergoing surgery were included in this study. A total of 188 children were observed without perforation, including 57 deaths (30.3%), and 83 children with perforation, including 24 deaths (28.9%). Preoperative cholestasis and time from NEC diagnosis to surgery were significantly different between the two groups (P < 0.05). Postoperative factors, including parenteral nutrition time (32 [3-94] days vs. 23 [1-53] days), enteral nutrition time (27 [0-86] days vs. 18 [0-81] days), NICU time (44 [5-125] days vs. 29 [1-92] days), and length of intestinal necrosis (15 [0-92] cm vs. 10 [2-70] cm), were significant. The mortality rate of patients with Bell stage IIIA was higher than that of patients with Bell stage IIIB. A total of 81 patients had 30-day postoperative mortality (57 non-perforated cases). Multivariate Cox regression analysis showed that non-perforation was a poor prognostic factor for survival outcome (hazard ratio 2.288, 95% confidence interval [1.329-3.940], P = 0.003). CONCLUSIONS Preterm infants in the non-perforated group had more serious complications and had a longer recovery time after surgery. Bell staging is not accurate in diagnosing severe NEC that needs surgical intervention.
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Affiliation(s)
- JinBao Han
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Gang Liu
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - MengNan Yu
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Guang Li
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - JianYing Cao
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Lian Duan
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - LiuMing Huang
- Department of Neonatal Surgery, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
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29
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Garg PM, Britt AB, Ansari MAY, Sobisek S, Block DK, Paschal JL, Ojeda NB, Askenazi D, Sanderson KR. Severe acute kidney injury in neonates with necrotizing enterocolitis: risk factors and outcomes. Pediatr Res 2021; 90:642-649. [PMID: 33446918 PMCID: PMC8277891 DOI: 10.1038/s41390-020-01320-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND To study the risk factors and outcomes of severe acute kidney injury (AKI) in neonates with necrotizing enterocolitis. METHODS Retrospective chart review of 202 neonates with necrotizing enterocolitis (NEC) (Bell stage >IIa) from 2013 to 2018. AKI was defined as per-modified neonatal Kidney Disease: Improving Global Outcomes criteria. Demographic, clinical, and outcome data were compared between neonates without severe AKI (stage 0 and 1 AKI) and those with severe AKI (stage 2 and 3 AKI). RESULTS Severe AKI occurred in 66/202 (32.6%) of neonates after NEC diagnosis and after 61/104 (58.7%) of surgical NEC diagnoses. On adjusted model, surgical NEC [adjusted odds ratio (aOR) = 30.6; 95% confidence interval (CI) = 8.9, 130.6], outborn [aOR = 3.9; 95% CI = 1.54, 11.0], exposure to antenatal steroids [aOR = 3.0; 95% CI = 1.1, 8.9], and positive blood culture sepsis [aOR = 3.5; 95% CI = 1.3, 10.0] had increased odds for severe AKI. Those with severe AKI required longer hospitalization [124 days (interquartile range (IQR) 88-187) vs. 82 days (IQR 42-126), p < 0.001]. CONCLUSIONS Severe AKI is common in neonates with NEC who require surgical intervention, are outborn, have positive blood culture sepsis, and receive antenatal steroids. Severe AKI is associated with a significantly longer length of hospitalization. IMPACT Neonates with NEC, who are transferred from outside hospitals, require surgical NEC management, and/or have a positive blood culture at NEC onset are at the highest odds for severe (stages 2 and 3) AKI. Assessment of urine output is important for patients with NEC. Without it, 11% of those with severe AKI would have been misdiagnosed using serum creatinine alone. Kidney-protective strategies in the pre-, peri-, and postoperative period may improve the morbidity and mortality associated with severe AKI in neonates with NEC.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Anna B. Britt
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sarah Sobisek
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Danielle K. Block
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jaslyn L. Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Norma B. Ojeda
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - David Askenazi
- Department of Pediatrics/ Nephrology, University of Alabama, Birmingham, AL, USA
| | - Keia R. Sanderson
- Department of Medicine, Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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30
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Abstract
Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.
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Affiliation(s)
- Jennifer Duchon
- Division of Newborn Medicine, Jack and Lucy Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1000 10th Avenue, New York, NY 10019, USA
| | - Maria E Barbian
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA
| | - Patricia W Denning
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Emory University Hospital Midtown, 550 Peachtree Street, 3rd Floor MOT, Atlanta, GA 30308, USA.
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31
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It's all in the milk: chondroitin sulfate as potential preventative therapy for necrotizing enterocolitis. Pediatr Res 2021; 89:1373-1379. [PMID: 32920604 PMCID: PMC8784957 DOI: 10.1038/s41390-020-01125-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/13/2020] [Accepted: 08/13/2020] [Indexed: 01/02/2023]
Abstract
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.
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32
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Elgendy MM, Othman HF, Heis F, Qattea I, Aly H. Spontaneous intestinal perforation in premature infants: a national study. J Perinatol 2021; 41:1122-1128. [PMID: 33674711 DOI: 10.1038/s41372-021-00990-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 01/15/2021] [Accepted: 02/03/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the prevalence and outcomes of spontaneous intestinal perforation (SIP) in very low birth weight infants. STUDY DESIGN This cross-sectional study utilized the National Inpatient Sample dataset for the years 2002-2017. All premature infants with birth weight (BW) <1500 g and with gestational age (GA) ≤32 weeks were included. Analyses were repeated after stratifying the population into two BW sub-categories <1000 g and 1000-1499 g. Trend analysis was done using Cochran-Armitage test. Regression analysis was conducted to control for gestational age, race, and sex. RESULT A total of 658,001 infants were included. SIP (n = 10,443, 1.6%) was mostly (81.9%) in the category <1000 g with 89.9% ≤28 weeks of gestation. There was a significant trend for increased SIP over the years (p < 0.001). SIP was associated with increased mortality (aOR = 2.24, CI: 2.04-2.46, p < 0.001). CONCLUSION After controlling for gestational age and other confounders, SIP is associated with increased mortality in premature infants.
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Affiliation(s)
- Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA.
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, MI, USA
| | - Farah Heis
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Ibrahim Qattea
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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Zhang H, Guo L, Ling K, Hu X, Li W, Li L. Specific imaging features of intestinal perforation on supine abdominal X-ray evaluation in infants with necrotizing enterocolitis. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000255. [DOI: 10.1136/wjps-2020-000255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022] Open
Abstract
BackgroundNecrotizing enterocolitis (NEC) is associated with high mortality and morbidity in neonates. For infants with NEC, intestinal perforation is the most serious complication, and confirming perforation and performing radical surgical treatment as early as possible may reduce mortality and sequelae. The aim of this study was to identify the specific imaging characteristics of intestinal perforation after NEC on supine abdominal X-ray for the early diagnosis of intestinal perforation.MethodsA retrospective study was conducted at the Children’s Hospital of Chongqing Medical University. Infants admitted to the hospital from 2013 to 2020 with NEC (Bell’s stage ≥Ⅱ) were divided into perforation and non-perforation groups. All infants were examined by abdominal X-ray in the erect and supine positions. The sensitivity and specificity of specific X-ray signs were analyzed.ResultsA total of 598 infants were included, 113 of whom suffered from perforation. On the supine abdominal films, lucency over the liver shadow, the liver falciform ligament sign, the football sign, the Rigler sign, the triangle sign and more than any one of the above signs had sensitivities of 64.60%, 45.13%, 37.17%, 30.97%, 15.93% and 86.73%, respectively. None of these signs were found on erect or supine abdominal films in the non-perforation group. The total of accuracy of prediction was 46.76%, and the specificity of all the signs was 100%.ConclusionSpecific signs on supine abdominal X-ray could be used to confirm perforation in neonates with NEC with 86.73% sensitivity and 100% specificity.
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[Role of fecal calprotectin in the diagnosis of neonatal necrotizing enterocolitis: a Meta analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33840411 PMCID: PMC8050553 DOI: 10.7499/j.issn.1008-8830.2010111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the value of fecal calprotectin (FC) in the diagnosis of neonatal necrotizing enterocolitis (NEC) through a Meta analysis. METHODS Web of Science, Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, Weipu Periodical Database, Wanfang Data, Chinese Biomedical Literature Database were searched for related studies published up to May 2020, with manual search as supplementation. The QUADAS criteria were used to evaluate the quality of the articles included. Meta-DiSc 1.4 and Stata 15.0 software were used to perform the Meta analysis, including the evaluation of specificity, sensitivity, likelihood ratio, and diagnostic odds ratio. The sensitivity analysis and heterogeneity testing were performed, and the summary receiver operating characteristic (SROC) curve and Fagan diagram were plotted. RESULTS A total of 15 articles were enrolled, involving 1 719 neonates. Among these articles, 4 had low quality, 2 had high quality, and the rest had medium quality. There was high heterogeneity between studies, and there was no threshold effect or publication bias. The random effects model analysis showed that FC had a pooled specificity of 0.80 (95%CI:0.78-0.82) and a sensitivity of 0.86 (95%CI:0.83-0.89) in the diagnosis of NEC, with a negative likelihood ratio of 0.19 (95%CI:0.14-0.26), a positive likelihood ratio of 4.71 (95%CI:3.57-6.23), and a diagnostic odds ratio of 29.56 (95%CI:17.98-48.61). The area under the SROC curve was 0.9131 and the Q* index was 0.8456. The Fagan diagram showed that the post-test probability of NEC indicated by negative FC was 13%, while that indicated by positive FC was 86%. The Meta regression analysis showed that the heterogeneity came from other non-threshold factors. CONCLUSIONS FC has high potential and efficiency in the early diagnosis of NEC. FC measurement can be used for the diagnosis of NEC, but it should be combined with clinical manifestations and other related laboratory examinations.
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Chen W, Yang C, Xue H, Huang Q. The protective effect and mechanism of epidermal growth factor on necrotizing enterocolitis in a neonatal rat model. Transl Pediatr 2021; 10:900-913. [PMID: 34012839 PMCID: PMC8107864 DOI: 10.21037/tp-21-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal emergency in premature infants. This study aimed to investigate the protective effect and mechanism of epidermal growth factor (EGF) on NEC in a neonatal rat model. METHODS We randomly divided 50 newborn SD rats into a control group, NEC group, NEC + 50 ng/mL EGF group, NEC + 500 ng/mL EGF group, and NEC + 1,000 ng/mL EGF group, with 10 cases in each group. The appearance of intestinal tissue, physiological status score, inflammatory factor level, HE staining, and pathological score were used to evaluate the protective effect. A one cm tissue sample from the proximal ileum of the ileocecal area of five rats from the NEC group and the group that showed a significant protective effect were extracted for transcriptome sequencing. RESULTS The levels of IL-1β and IL-6 in the intestinal mucosa in the NEC + 500 ng/mL EGF group were significantly lower than those in the NEC + 1,000 ng/mL EGF group (P<0.05). Transcriptome sequencing suggested that EGF effects the intestinal barrier, apoptosis, and inflammation of the NEC intestine. CONCLUSIONS We conclude that the oral administration of 500 ng/mL EGF effectively inhibits intestinal inflammation in NEC neonatal rat models, thereby affecting the barrier function of the intestinal tract.
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Affiliation(s)
- Wenqian Chen
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Changyi Yang
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Heng Xue
- Department of Laboratory Medicine, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qi Huang
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Harky A, Kashif H, Abuelgasim E, Hussain N, Luyt J. Necrotizing enterocolitis and congenital heart disease. Ann Pediatr Cardiol 2021; 14:507-515. [PMID: 35527771 PMCID: PMC9075549 DOI: 10.4103/apc.apc_30_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/26/2021] [Indexed: 11/25/2022] Open
Abstract
Necrotizing enterocolitis (NEC) remains a prominent surgical emergency among infant population, associated with a significant mortality, as well as various subsequent morbidities. Congenital heart disease (CHD) has an increased associated incidence with NEC in infant population. Recent research has provided insight into the pathophysiology of NEC in patients with CHD and how this differs from those without CHD. The deviation from normal circulatory physiology has a suggested association in the pathophysiology of NEC in CHD, which may have implications for the risk factors of NEC in infants with CHD, the effect on outcomes of NEC, and whether alternative approaches to management may need to be considered in comparison to classical NEC. This review aims to highlight studies that provide insight and awareness into the relationship between NEC and CHD, in order that clinicians may direct themselves more clearly toward optimal management for infants in this category.
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Perrone S, Cremonini I, Marinelli F, Monaco S, Nicoletti L, Giordano M, Esposito S. New Strategies for Necrotizing Enterocolitis Diagnosis and Prevention in Newborns. Curr Pediatr Rev 2021; 17:191-200. [PMID: 33902422 DOI: 10.2174/1573396317666210426102610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/27/2020] [Accepted: 02/23/2021] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis is one of the most frequent and severe gastrointestinal diseases that affect preterm newborns in Neonatal Intensive Care Units. It was firstly described in 1960s, but this clinical entity was not widely recognized until the advent of modern neonatal intensive care. The disease is characterized by submucosal edema, infiltration of intestinal wall by immune cells, specifically neutrophils and, in severe forms, wall necrosis that leads to intestinal perforation. Its incidence is inversely associated to birth weight and gestational age. Necrotizing enterocolitis has been responsible for high rates of morbidity and mortality (15-30%), despite improvements made in neonatal care in the last decades. The challenge is to optimize strategies for early diagnosis, define the best medical and surgical treatments and standardize preventive measures. Several biomarkers have been proposed for the early prediction of necrotizing enterocolitis onset in preterm newborns and can be useful not only for diagnostic purposes but also for prediction of disease progression and severity. The purpose of this paper is to illustrate the most recent evidence regarding the diagnosis and prevention of necrotizing enterocolitis. This manuscript contributes to clinical decision-making in preterm neonates at high risk of developing necrotizing enterocolitis.
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Affiliation(s)
- Serafina Perrone
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | - Sara Monaco
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Laura Nicoletti
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maurizio Giordano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Susanna Esposito
- Department of Medicine and Surgery, University of Parma, Parma, Italy
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Garg PM, O’Connor A, Ansari MAY, Vu B, Hobart H, Paschal JL, Multani H, Josephson CD, Okhomina V. Hematological predictors of mortality in neonates with fulminant necrotizing enterocolitis. J Perinatol 2021; 41:1110-1121. [PMID: 33772112 PMCID: PMC7995678 DOI: 10.1038/s41372-021-01044-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/13/2021] [Accepted: 03/10/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Determine whether hematological and transfusion patterns following, the onset of NEC can identify infants likely to develop fulminant, fatal necrotizing enterocolitis (NEC). DESIGN Determine hematological predictors of fulminant NEC. RESULTS Of 336 neonates with NEC, 35 (10%) who developed fulminant NEC were born with higher birth weights and more frequently developed radiologically evident pneumoperitoneumand/or portal venous gas. Following the diagnosis of NEC, these infants were more likely to rapidly develop thrombocytopenia, lymphopenia, neutropenia, and lower total white blood cell counts compared to medical/surgical non-fulminant type. They were also more likely to have received a red blood cell (RBC) transfusion (76.7% vs. 53.1%, p = 0.001) within 48 h after disease onset and platelet transfusion (24.2% vs. 11.7%; p = 0.03) before the onset of NEC. CONCLUSION Neonates with fulminant NEC frequently developed thrombocytopenia, lymphopenia, neutropenia, and leukopenia, received RBC transfusions after or platelet transfusions before the onset of NEC developed the fulminant disease.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Anna O’Connor
- grid.410721.10000 0004 1937 0407Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS USA
| | - Md Abu Yusuf Ansari
- grid.410721.10000 0004 1937 0407Department of Data Science, University of Mississippi Medical Center, Jackson, MS USA
| | - Binh Vu
- grid.410721.10000 0004 1937 0407Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS USA
| | - Haley Hobart
- grid.410721.10000 0004 1937 0407Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS USA
| | - Jaslyn L. Paschal
- grid.410721.10000 0004 1937 0407Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS USA
| | - Harleen Multani
- grid.410721.10000 0004 1937 0407Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS USA
| | - Cassandra D. Josephson
- grid.189967.80000 0001 0941 6502Department of Pathology, Emory Center for Transfusion and Cellular Therapies, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Victoria Okhomina
- grid.410721.10000 0004 1937 0407Department of Data Science, University of Mississippi Medical Center, Jackson, MS USA
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Clinical determinants of postoperative outcomes in surgical necrotizing enterocolitis. J Perinatol 2020; 40:1671-1678. [PMID: 32669645 DOI: 10.1038/s41372-020-0728-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Investigate predictors of postoperative morbidity and mortality in surgical NEC. STUDY DESIGN We analyzed the clinical outcomes of infants with surgical NEC from the years 2000-2015. RESULTS Ninety infants born at gestation (mean ± standard deviation, SD; standard error of mean, SEM) 27.3 ± 6.6 weeks (SEM ± 0.07 weeks) and weighing 1008 ± 456 g (SEM ± 48 g) developed NEC on 25.2 ± 22.4 days (SEM ± 2.4 days). Average bowel resection was 29.2 ± 30.5 cm (SEM ± 3.2 cm). Postoperative Ileus lasted 16.5 ± 12.2 days (SEM ± 1.3 days), and was significantly longer in infants with higher gestation and birth weight, age at onset of NEC, length of intestinal resection, maternal chorioamnionitis, and need for pressors. Thirty-eight (42.2%) infants died. Mortality was higher at gestation <31 weeks. CONCLUSION Gestational age, birth weight, age at NEC onset, and length of resected bowel determined postoperative morbidity and mortality in NEC. Length of hospital stay was affected by above factors, and also the duration of postoperative ileus and parenteral nutrition.
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Abstract
We aim to summarize the evidence focusing on the effects of various doses of human milk on the risk of neonatal necrotizing enterocolitis (NEC). The eligible articles in the study were those investigating the association between human milk and NEC published before June 26, 2019, in the PubMed, EMBASE, the Cochrane Library, VIP database, CNKI database, and Wangfang database. The included criteria were as follows: premature infants of <37 weeks; randomly controlled trials (RCTs); those fed by mother's own milk or donor human milk; studies focused on the comparison of human milk and formula milk, involving various breast milk doses; and NEC-related studies. Compared with the exclusive formula, the incidence of NEC in the infants fed by exclusive human milk was significantly lower. The incidence of NEC in the infants fed by exclusive human milk was significantly lower than that of partial human milk [risk ratio (RR) = 0.54, 95% confidence interval (95% CI): 0.36-0.79, P < .05]. The incidence of NEC in the infants fed mainly by human milk was significantly lower than that of mainly fed by formula. Incidence of NEC in the infants fed by exclusive human milk was significantly lower than that of any formula (RR = 0.49, 95% CI: 0.34-0.71, P < .05). In summary, this meta-analysis was based on the RCTs involving the prevention of NEC using human milk. Exclusive human milk and partial human milk reduced the incidence of NEC in premature infants, especially in the those fed by high proportion of human milk. In addition, more RCTs are needed to further validate such conclusion.
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Affiliation(s)
- Baoquan Zhang
- Neonatology Department, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenlong Xiu
- Neonatology Department, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yue Dai
- Health Research Institute of Fujian Medical University, Fuzhou, China
| | - Changyi Yang
- Neonatology Department, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Han SM, Hong CR, Knell J, Edwards EM, Morrow KA, Soll RF, Modi BP, Horbar JD, Jaksic T. Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: A multicenter cohort analysis. J Pediatr Surg 2020; 55:998-1001. [PMID: 32173122 DOI: 10.1016/j.jpedsurg.2020.02.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/20/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We sought to describe changes in the incidence and mortality of necrotizing enterocolitis (NEC) and associated surgical management strategies for very low birth weight (VLBW) infants. METHODS Data were prospectively collected on VLBW infants (≤1500 g or < 29 weeks) born 2006 to 2017 and admitted to 820 U.S. centers. NEC was defined by the presence of at least one clinical and one radiographic finding. Trends analyses were performed to assess changes in incidence and mortality over time. RESULTS Of 473,895 VLBW infants, 36,130 (7.6%) were diagnosed with NEC, of which 21,051 (58.3%) had medical NEC and 15,079 (41.7%) had surgical NEC. Medical NEC decreased from 5.3% to 3.0% (p < 0.0001). Surgical NEC decreased from 3.4% to 3.1% (p = 0.06). Medical NEC mortality decreased from 20.7% to 16.8% (p = 0.003), while surgical NEC mortality decreased from 36.6% to 31.6% (p < 0.0001). In the surgical cohort, the use of primary peritoneal drainage (PPD) versus initial laparotomy rose from 23.2% to 46.8%. CONCLUSION The incidence and mortality of both medical and surgical NEC have decreased over time. Changes in surgical management during this time period included the increased utilization of primary peritoneal drainage. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sam M Han
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Charles R Hong
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jamie Knell
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Erika M Edwards
- University of Vermont and Vermont Oxford Network, Burlington, VT, USA
| | | | - Roger F Soll
- University of Vermont and Vermont Oxford Network, Burlington, VT, USA
| | - Biren P Modi
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeffrey D Horbar
- University of Vermont and Vermont Oxford Network, Burlington, VT, USA
| | - Tom Jaksic
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Han SM, Knell J, Henry O, Riley H, Hong CR, Staffa SJ, Modi BP, Jaksic T. Long-term outcomes of severe surgical necrotizing enterocolitis. J Pediatr Surg 2020; 55:848-851. [PMID: 32085915 DOI: 10.1016/j.jpedsurg.2020.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE We sought to describe long-term outcomes of infants with severe surgical necrotizing enterocolitis (NEC). METHODS Data were collected on infants with surgical NEC (2009-2018). Severe surgical NEC was defined by extensive bowel loss with residual bowel length <30 cm, and "NEC totalis" was identified per operative report. Post-operative management and long-term outcomes were assessed, including enteral autonomy, severe neurodevelopmental disability, and educational attainment. RESULTS Of 268 infants with surgical NEC, 41 (15%) had severe surgical NEC, and 14/41 were identified as "NEC totalis". Zero severe NEC vs. 8 (57%) "NEC totalis" patients were placed on comfort measures following initial surgery (p < 0.001). Twenty-five patients (93%) with severe NEC survived vs 3/6 with "NEC totalis" (p < 0.001). The 28 survivors (68%) were followed for a median (IQR) duration of 8(4,10) years. Nine (32%) with severe NEC were weaned from parenteral nutrition. Eight (29%) had ≥1 marker for severe neurodevelopmental disability, and 11/16(69%) (7-16 years) were attending school at last follow-up. CONCLUSION Long-term survival is excellent following initial discharge, and achievement of enteral autonomy is feasible in patients with severe surgical NEC. The majority of patients who survive do not have severe neurodevelopmental disability and participate in school. Given current survivals and outcomes, focus on measured residual bowel length may be more appropriate than the subjective term "NEC-totalis." TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sam M Han
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jamie Knell
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Owen Henry
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Heather Riley
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Diez S, Tielesch L, Weiss C, Halbfass J, Müller H, Besendörfer M. Clinical Characteristics of Necrotizing Enterocolitis in Preterm Patients With and Without Persistent Ductus Arteriosus and in Patients With Congenital Heart Disease. Front Pediatr 2020; 8:257. [PMID: 32582588 PMCID: PMC7289954 DOI: 10.3389/fped.2020.00257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/24/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Diagnosis and management of NEC is based on clinical, radiological, and laboratory findings. Discrimination of pathogens for an improved understanding of NEC in preterm infants and NEC in infants with congenital heart disease has been previously discussed and enables evaluation of further NEC biomarkers. Patients and Methods: Within a study period of 11 years (2008-2019), we identified 107 patients with a diagnosis of NEC at our primary care center. Thirty-six out of 54 patients suffering from NEC in high Bell stages who underwent surgery met inclusion criteria. These patients were classified according to their cardiac status, and analyses of clinical factors influencing NEC were conducted. Additionally, clinical factors associated with a fulminant course of NEC were examined. Univariable and multivariable analyses were performed. Results: The study populations consisted of 12 preterm infants with NEC but without patent ductus arteriosus (PT-NEC), seven preterm infants with NEC and patent ductus arteriosus (PDA-NEC), and 17 infants with NEC and congenital heart disease (CHD-NEC). Blood flow in intestinal vessels was impaired in infants with PDA-NEC and CDH-NEC. Therefore, we used logistic regression to compare PDA-NEC and CDH-NEC infants with PT-NEC infants: positive bacterial culture of intraoperative swabs (p = 0.0199; odds ratio: 21.9) and macroscopic intestinal necrosis (p = 0.0033; odds ratio: 43.5) were observed more frequently in the first group. Furthermore, multiple regression analysis determined the NEC localization (p = 0.0243) as a significant factor correlated with a fulminant course. Compared to a NEC exclusively localized in the colon, there is a 5.8-fold increased risk of a fulminant course when the small intestine is affected and a 42-fold increase of risk when both small intestine and colon were affected. Conclusion: An early diagnosis and timely surgical intervention of NEC, especially in infants with PDA and CDH may be considered to avoid major bowel necrosis (resulting in loss of intestinal tissue) and multiple operations.
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Affiliation(s)
- Sonja Diez
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Lea Tielesch
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Christel Weiss
- Department of Medical Statistics & Biomathematics, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julia Halbfass
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Pediatric Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Hanna Müller
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Neonatology and Pediatric Intensive Care, Hospital for Children and Adolescents, University Hospital Erlangen, Erlangen, Germany
| | - Manuel Besendörfer
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
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Holgersen K, Gao X, Narayanan R, Gaur T, Carey G, Barton N, Pan X, Muk T, Thymann T, Sangild PT. Supplemental Insulin-Like Growth Factor-1 and Necrotizing Enterocolitis in Preterm Pigs. Front Pediatr 2020; 8:602047. [PMID: 33614541 PMCID: PMC7891102 DOI: 10.3389/fped.2020.602047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/18/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Recombinant human IGF-1/binding protein-3 (rhIGF-1/BP-3) is currently tested as a therapy in preterm infants but possible effects on the gut, including necrotizing enterocolitis (NEC), have not been tested. The aim of this study was to evaluate if rhIGF-1/BP-3 supplementation in the first days after birth negatively affects clinical variables like growth, physical activity, blood chemistry and hematology and gut maturation (e.g., intestinal permeability, morphology, enzyme activities, cytokine levels, enterocyte proliferation, NEC lesions), using NEC-sensitive preterm pigs as a model for preterm infants. Methods: Preterm pigs were given twice daily subcutaneous injections of rhIGF-1/BP-3 or vehicle. Blood was collected for IGF-1 measurements and gut tissue for NEC evaluation and biochemical analyses on day 5. Results: Baseline circulating IGF-1 levels were low in preterm pigs compared with near-term pigs reared by their mother (<20 vs. 70 ng/ml). Injection with rhIGF-1/BP-3 resulted in increased plasma IGF-1 levels for up to 6 h after injection (>40 ng/mL). rhIGF-1/BP-3 treatment reduced the incidence of severe NEC lesions (7/24 vs.16/24, p = 0.01) and overall NEC severity (1.8 ± 0.2 vs. 2.6 ± 0.3, p < 0.05, with most lesions occurring in colon). In the small intestine, villi length (405 ± 25 vs. 345 ± 33 μm) and activities of the brush border peptidases aminopeptidase N and dipeptidylpeptidase IV were increased in rhIGF-1/BP-3 treated pigs, relative to control pigs (+31-44%, both p < 0.05). The treatment had no effects on body weight, blood chemistry or hematology, except for an increase in blood leucocyte and neutrophil counts (p < 0.05, i.e., reduced neonatal neutropenia). Likewise, rhIGF-1/BP-3 treatment did not affect intestinal tissue cytokine levels (IL-1β, IL-6, IL-8, TNFα,), enterocyte proliferation, goblet cell density, permeability or bacterial translocation to the bone marrow. Conclusion: Supplemental rhIGF-1/BP-3 did not negatively affect any of the measured variables of clinical status or gut maturation in preterm pigs. Longer-term safety and efficacy of exogenous rhIGF-1/BP-3 to support maturation of the gut and other critical organs in preterm newborns remain to be investigated in both pigs and infants.
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Affiliation(s)
- Kristine Holgersen
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Xiaoyan Gao
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark.,Department of Neonatology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, China
| | | | | | | | | | - Xiaoyu Pan
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Tik Muk
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Per Torp Sangild
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark.,Department of Neonatology, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatrics, Odense University Hospital, Odense, Denmark
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