Necrotizing enterocolitis in the premature infant: neonatal nursing assessment, disease pathogenesis, and clinical presentation

Correlation of Polymorphonuclear Cell Burden and Microbial Growth to the Inflammatory Cytokines in Tracheal Aspirates from Ventilated Preterm Infants

OBJECTIVE

 The significance of the presence of microorganisms and polymorphonuclear cells in the tracheal aspirates (TAs) of ventilated preterm infants is not well known. Our aim was to correlate information about the presence of polymorphonuclear cells with microbial growth and the cytokine milieu in the TAs of infants who have been intubated for >7 days.

STUDY DESIGN

 TAs were collected from infants who had been intubated for 7 days or longer. Respiratory cultures were performed, and infants were stratified based on the presence and abundance of polymorphonuclear cells and microbial growth. Cytokines were measured in the TAs of each of the respective groups.

RESULTS

 In the 19 infants whose TAs were collected, the presence of at least moderate WBC with presence of microbial growth was positively associated with the presence of interleukin (IL)-10, IL-1β, IL-8, and tumor necrosis factor (TNF)-α. The presence of at least moderate WBC, with or without microbial growth, was correlated positively with the presence of IL-8 and TNF-α.

CONCLUSION

 There are higher levels of proinflammatory cytokines (especially, IL-10, IL-1β, and TNF-α) in TAs with higher cell counts and presence of microbial growth. The findings suggest that the presence of microbial growth correlated with inflammatory burden and warrant a larger study to see if treatment of microbial growth can ameliorate the inflammatory burden.

KEY POINTS

· Concomitant evaluation of inflammatory cells, microbial growth, and cytokines in tracheal aspirates.. · Moderate TA WBC with presence of microbial growth associated with IL-10, IL-1β, IL-8, and TNF-α.. · Moderate TA WBC, with/without microbial growth, correlated with the presence of IL-8 and TNF-α.. · Higher levels of IL-10, IL-1β, and TNF-α correlated with higher TA cell counts and microbial growth..

Photoacoustic imaging for non-invasive assessment of biomarkers of intestinal injury in experimental necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is an often-lethal disease of the premature infant intestinal tract, exacerbated by significant diagnostic difficulties. In NEC, the intestine exhibits hypoperfusion and dysmotility, contributing to disease pathogenesis. However, these features cannot be accurately and quantitively assessed with current imaging modalities. We have previously demonstrated the ability of photoacoustic imaging (PAI) to non-invasively assess intestinal tissue oxygenation and motility in a healthy neonatal rat model.

METHODS

In this first-in-disease application, we evaluated NEC using PAI to assess intestinal health biomarkers in an experimental model of NEC. NEC was induced in neonatal rats from birth to 4-days. Healthy breastfed (BF) and NEC rat pups were imaged at 2- and 4-days.

RESULTS

Intestinal tissue oxygen saturation was measured with PAI, and NEC pups showed significant decreases at 2- and 4-days. Ultrasound and PAI cine recordings were used to capture intestinal peristalsis and contrast agent transit within the intestine. Intestinal motility, assessed using computational intestinal deformation analysis, demonstrated significant reductions in both early and established NEC. NEC damage was confirmed with histology and dysmotility was confirmed by small intestinal transit assay.

CONCLUSION

This preclinical study presents PAI as an emerging diagnostic imaging modality for intestinal disease assessment in premature infants.

IMPACT

Necrotizing enterocolitis (NEC) is a devastating intestinal disease affecting premature infants with significant mortality. NEC presents significant clinical diagnostic difficulties, with limited diagnostic confidence complicating timely and effective interventional efforts. This study is an important foundational first-in-disease preclinical study that establishes the utility for PAI to detect changes in intestinal tissue oxygenation and intestinal motility with NEC disease induction and progression. This study demonstrates the feasibility and exceptional promise for the use of PAI to non-invasively assess oxygenation and motility in the healthy and diseased infant intestine.

Repeated intravenous doses of human umbilical cord-derived mesenchymal stromal cells for bronchopulmonary dysplasia: results of a phase 1 clinical trial with 2-year follow-up

BACKGROUND

Currently, there is a lack of effective treatments or preventive strategies for bronchopulmonary dysplasia (BPD). Pre-clinical studies with mesenchymal stromal cells (MSCs) have yielded encouraging results. The safety of administering repeated intravenous doses of umbilical cord tissue-derived mesenchymal stromal cells (UC-MSCs) has not yet been tested in extremely-low-gestational-age newborns (ELGANs).

AIMS

to test the safety and feasibility of administering three sequential intravenous doses of UC-MSCs every 7 days to ELGANs at risk of developing BPD.

METHODS

In this phase 1 clinical trial, we recruited ELGANs (birth weight ≤1250 g and ≤28 weeks in gestational age [GA]) who were on invasive mechanical ventilation (IMV) with FiO2 ≥ 0.3 at postnatal days 7-14. Three doses of 5 × 106/kg of UC-MSCs were intravenously administered at weekly intervals. Adverse effects and prematurity-related morbidities were recorded.

RESULTS

From April 2019 to July 2020, 10 patients were recruited with a mean GA of 25.2 ± 0.8 weeks and a mean birth weight of 659.8 ± 153.8 g. All patients received three intravenous UC-MSC doses. The first dose was administered at a mean of 16.6 ± 2.9 postnatal days. All patients were diagnosed with BPD. All patients were discharged from the hospital. No deaths or any serious adverse events related to the infusion of UC-MSCs were observed during administration, hospital stays or at 2-year follow-up.

CONCLUSIONS

The administration of repeated intravenous infusion of UC-MSCs in ELGANs at a high risk of developing BPD was feasible and safe in the short- and mid-term follow-up.

A Nomogram for Predicting Surgical Risk in Neonates with Necrotizing Enterocolitis: A Retrospective Cohort Study

OBJECTIVES

To construct a nomogram that predicts the risk of surgery in patients with necrotizing enterocolitis (NEC).

METHODS

This retrospective cohort study recruited patients diagnosed with NEC at the Children's Hospital of Soochow University from 2013 to 2023. The neonates were divided into conservative and surgical-treatment groups. Univariate and multivariate logistic regressions were performed to identify factors influencing surgical risk, and a predictive model was constructed.

RESULTS

This study comprised 154 cases of NEC, 103 cases (66.9%) in the conservative group and 51 cases (33.1%) in the surgical group. Multivariate logistic regression analysis revealed that increased bloody stools [odds ratio (OR) 5.066; 95% confidence interval (CI) 1.7396-14.7532; p = 0.0029), oxygen inhalation (OR 1.8278; 95% CI 1.2113-2.7581; p = 0.0041), use of vasoconstrictors (OR 4.4446; 95% CI 1.7157-11.5137; p = 0.0021), portal venous gas (OR 4.5569; 95% CI 1.6324-12.7209; p = 0.0038), and blood sodium (OR 0.8339; 95% CI 0.7477-0.9301; p = 0.0011) were independent factors of surgical risk. The area under the nomogram's receiver operating characteristic (ROC) curve was 0.886. Decision curve analysis (DCA) and calibration curves demonstrated good predictive performance for the nomogram.

CONCLUSIONS

The nomogram effectively assessed the risk of surgical intervention in NEC patients, providing new insights and references for diagnosing and treating NEC.

Respiratory Complications in Infants with Retinopathy of Prematurity (ROP) Requiring Laser Photocoagulation

OBJECTIVE

 The objective of this paper was to describe peri-procedural events and complications of infants requiring laser photocoagulation for retinopathy of prematurity (ROP) in a level IV neonatal intensive care unit.

STUDY DESIGN

 A retrospective chart review was performed of neonates requiring ROP exams from January 2017 to August 2020. Baseline maternal and neonatal characteristics, ROP exam findings, and associated treatment were analyzed. Group characteristics were compared based on the need for laser photocoagulation. Subgroup analysis of the laser group including respiratory outcomes, cardiorespiratory index (CRI) scores, and pain scores was also performed.

RESULTS

 Neonatal and maternal characteristics in the laser (n = 27) and non-laser (n = 172) groups were assessed. Of the 81.5% (22/27) that required re-intubation for laser, 36% (8/22) had >1 intubation and 18% (4/22) had >1 extubation attempt. The average duration of intubation following laser was 2.46 ± 7.13 days, with 40% (9/22) needing peri-extubation steroids and 18% (4/22) racemic epinephrine to facilitate extubation. Mean total respiratory support time post-laser was 8.65 ± 15.23 days. Mean neonatal pain, agitation, and sedation scores after laser were zero immediately after the procedure, 0.09 ± 0.33 at 12 hours, 0.11 ± 0.47 at 24 hours, and 0.11 ± 0.51 at 48 hours. The mean CRI scores were 1 ± 0 immediately after the procedure, 1.17 ± 0.4 at 12 hours, 1.41 ± 0.20 at 24 hours, and 1 ± 0 at 48 hours.

CONCLUSION

 Nearly all infants undergoing laser photocoagulation for ROP in our cohort required intubation and continued respiratory support. Despite stability during the procedure, complications from intubation were common.

KEY POINTS

· Routine intubation for laser is associated with complications.. · Need for post-procedural respiratory support is common.. · Avoiding intubation may mitigate these neonatal complications..

Language performance and brain volumes, asymmetry, and cortical thickness in children born extremely preterm

BACKGROUND

Children born preterm are more prone to have language difficulties. Few studies focus on children born extremely preterm (EPT) and the structural differences in language-related regions between these children and children born at term.

METHODS

Our study used T1-weighted magnetic resonance imaging (MRI) scans to calculate the brain volumetry, brain asymmetry, and cortical thickness of language-related regions in 50 children born EPT and 37 term-born controls at 10 years of age. The language abilities of 41 of the children born EPT and 29 term-born controls were then assessed at 12 years of age, using the Wechsler Intelligence Scale for Children, Fifth Edition and the Clinical Evaluations of Language Fundamentals, Fourth Edition. The differences between MRI parameters and their associations with language outcomes were compared in the two groups.

RESULTS

Brain volume and cortical thickness of language-related regions were reduced in children born EPT, but volumetric asymmetry was not different between children born EPT and at term. In children born EPT the brain volume was related to language outcomes, prior to adjustments for full-scale IQ.

CONCLUSIONS

These findings expand our understanding of the structural correlates underlying impaired language performance in children born with EPT.

IMPACT

The article expands understanding of the structure-function relationship between magnetic resonance imaging measurements of language-related regions and language outcomes for children born extremely preterm beyond infancy. Most literature to date has focused on very preterm children, but the focus in this paper is on extreme prematurity and language outcomes. While the brain volume and cortical thickness of language-related regions were reduced in children born EPT only the volume, prior to adjustment for full-scale IQ, was associated with language outcomes. We found no differences in volumetric asymmetry between children born EPT and at term.

Clostridium scindens exacerbates experimental necrotizing enterocolitis via upregulation of the apical sodium-dependent bile acid transporter

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in premature infants. Evidence indicates that bile acid homeostasis is disrupted during NEC: ileal bile acid levels are elevated in animals with experimental NEC, as is expression of the apical sodium-dependent bile acid transporter (Asbt). In addition, bile acids, which are synthesized in the liver, are extensively modified by the gut microbiome, including via the conversion of primary bile acids to more cytotoxic secondary forms. We hypothesized that the addition of bile acid-modifying bacteria would increase susceptibility to NEC in a neonatal rat model of the disease. The secondary bile acid-producing species Clostridium scindens exacerbated both incidence and severity of NEC. C. scindens upregulated the bile acid transporter Asbt and increased levels of intraenterocyte bile acids. Treatment with C. scindens also altered bile acid profiles and increased hydrophobicity of the ileal intracellular bile acid pool. The ability of C. scindens to enhance NEC requires bile acids, as pharmacological sequestration of ileal bile acids protects animals from developing disease. These findings indicate that bile acid-modifying bacteria can contribute to NEC pathology and provide additional evidence for the role of bile acids in the pathophysiology of experimental NEC.NEW & NOTEWORTHY Necrotizing enterocolitis (NEC), a life-threatening gastrointestinal emergency in premature infants, is characterized by dysregulation of bile acid homeostasis. We demonstrate that administering the secondary bile acid-producing bacterium Clostridium scindens enhances NEC in a neonatal rat model of the disease. C. scindens-enhanced NEC is dependent on bile acids and driven by upregulation of the ileal bile acid transporter Asbt. This is the first report of bile acid-modifying bacteria exacerbating experimental NEC pathology.

SNAPPE-II and MDAS scores as predictors for surgical intervention in very low birth weight neonates with necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in preterm and term neonates, with the majority of cases affecting neonates classified as very low birth weight (VLBW, bw <1500 g). Scores for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and metabolic derangement acuity score (MDAS) have been developed and utilized to assess neonatal morbidity and mortality including the subset of VLBW neonates. Serial SNAPPE-II and MDAS scores have been reported in neonates with necrotizing enterocolitis to assist in surgical management, yielding mixed results.

OBJECTIVE

To determine the relationship between clinical and/or laboratory deterioration using SNAPPE-II and MDAS scores measured at the time of NEC diagnosis and surgical management of NEC.

METHODS

We retrospectively evaluated preterm neonates ≥23 weeks gestational age who developed pneumatosis intestinalis on radiographic imaging coupled with clinical signs of NEC. SNAPPE-II and MDAS scores were calculated within twelve hours of birth and within twelve hours of initial finding of pneumatosis intestinalis. Baseline characteristics and clinical variables between those who did and did not require surgical intervention were compared. Logistic regression and receiver - operator characteristics (ROC) curve analyses were also performed, and areas under the curve (AUC) computed, to assess the performance of SNAPPE-II and MDAS scoring systems to differentiate neonates with NEC in the two groups.

RESULTS

Sixty-four neonates were evaluated in our study of which 20 required surgical management of NEC. While the baseline SNAPPE-II and MDAS scores did not differ between the surgical management and medical management only groups, when rescored within 12 h of NEC diagnosis, the surgical management group had significantly higher SNAPPE -II (38 (18.5-69) vs. 19 (10-34.5), p = .04) and MDAS (2.5 (1-3) vs. 1 (0-2), p = .0004) scores. The AUCs for MDAS 0.77 (95% CI 0.65-0.89 and 0.71 (95% CI 0.57-0.85) for SNAPPE-II, indicating an acceptable level of diagnostic ability of both scoring systems to differentiate between those who did and did not need surgical management.

CONCLUSION

SNAPPE II and MDAS scores performed within 12 h of NEC diagnosis may be useful in predicting which preterm VLBW neonates will require surgical intervention.

Photoacoustic Imaging for Non-Invasive Assessment of Physiological Biomarkers of Intestinal Injury in Experimental Necrotizing Enterocolitis

Background

Necrotizing enterocolitis (NEC) is an often-lethal disease of the premature infants' intestinal tract that is exacerbated by significant difficulties in early and accurate diagnosis. In NEC disease, the intestine often exhibits hypoperfusion and dysmotility, which contributes to advanced disease pathogenesis. However, these physiological features cannot be accurately and quantitively assessed within the current constraints of imaging modalities frequently used in the clinic (plain film X-ray and ultrasound). We have previously demonstrated the ability of photoacoustic imaging (PAI) to non-invasively and quantitively assess intestinal tissue oxygenation and motility in a healthy neonatal rat model. As a first-in-disease application, we evaluated NEC pathogenesis using PAI to assess intestinal health biomarkers in a preclinical neonatal rat experimental model of NEC.

Methods

NEC was induced in neonatal rat pups from birth to 4 days old via hypertonic formula feeding, full-body hypoxic stress, and lipopolysaccharide administration to mimic bacterial colonization. Healthy breastfed (BF) controls and NEC rat pups were imaged at 2- and 4-days old. Intestinal tissue oxygen saturation was measured with PAI imaging for oxy- and deoxyhemoglobin levels. To measure intestinal motility, ultrasound and co-registered PAI cine recordings were used to capture intestinal peristalsis motion and contrast agent (indocyanine green) transit within the intestinal lumen. Additionally, both midplane two-dimensional and volumetric three-dimensional imaging acquisitions were assessed for oxygenation and motility.

Results

NEC pups showed a significant decrease of intestinal tissue oxygenation as compared to healthy BF controls at both ages (2-days old: 55.90% +/- 3.77% vs 44.12% +/- 7.18%; 4-days old: 56.13% +/- 3.52% vs 38.86% +/- 8.33%). Intestinal motility, assessed using a computational intestinal deformation analysis, demonstrated a significant reduction in the intestinal motility index in both early (2-day) and established (4-day) NEC. Extensive NEC damage was confirmed with histology and dysmotility was confirmed by small intestinal transit assay.

Conclusions

This study presents PAI as a successful emerging diagnostic imaging modality for both intestinal tissue oxygenation and intestinal motility disease hallmarks in a rat NEC model. PAI presents enormous significance and potential for fundamentally changing current clinical paradigms for detecting and monitoring intestinal pathologies in the premature infant.

SIGIRR gene variants in term newborns with congenital heart defects and necrotizing enterocolitis

Background

Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency among neonates which is characterized by acute intestinal inflammation and necrosis. The main risk factors for NEC are prematurity, low birth weight, and some preexisting health conditions such as congenital heart defects (CHDs). Investigation of the potential genetic predisposition to NEC is a promising approach that might provide new insights into its pathogenesis. One of the most important proteins that play a significant role in the pathogenesis of NEC is Toll-like receptor 4 (TLR4) which recognizes lipopolysaccharide found in Gram-negative bacteria. In intestinal epithelial cells, a protein encoded by the SIGIRR gene is a major inhibitor of TLR4 signaling. A few SIGIRR variants, including rare p.Y168X and p.S80Y, have already been identified in preterm infants with NEC, but their pathogenic significance remains unclear. This study aimed to investigate the spectrum of SIGIRR genetic variants in term newborns with CHD and to assess their potential association with NEC.

Methods and Results

A total of 93 term newborns with critical CHD were enrolled in this study, 33 of them developed NEC. SIGIRR genetic variants were determined by Sanger sequencing of all exons. In total, eight SIGIRR genetic variants were identified, two of which were found only in newborns with NEC (P = 0.12). The rare missense p.S80Y (rs117739035) variant in exon 4 was found in two infants with NEC stage IIA. Two infants with NEC stage III and stage IB carried a novel duplication c. 102_121dup (rs552367848) variant in exon 10 that has not been previously associated with any clinical phenotype.

Conclusions

The presence of both variants only in neonates who developed NEC, together with earlier published data, may suggest their potential contribution to the risk of developing NEC in term infants with CHD and allow planning larger cohort studies to clarify their relevance.

Can Enterococcus faecium prevent NEC in preterm infants?: A systematic review and meta-analysis

OBJECTIVE

Previous some systematic reviews reported that probiotics may benefit the prevention of NEC in preterm infants. But dissimilar bacterial strains and taxa used in included studies possibly result in bias. There is not a rounded systematic review which has estimated the benefit and safety of Enterococcus faecium to prevent NEC in preterm infants to date before we conducted.

METHODS

This systematic review of randomized controlled trials and retrospective studies analyzing the benefit of Enterococcus faecium to prevent NEC in preterm infants was performed using PubMed, Web of Science, Cochrane Library, EMBASE, Wanfang data and China National Knowledge Infrastructure databases from inception to April 14, 2023. The search terms were "preterm" AND "necrotizing enterocolitis" AND "Enterococcus faecium OR probiotics." Studies reporting NEC involving preterm infants who were given Enterococcus faecium were included in this systematic review. A sensitivity analysis was conducted to assess the stability of results. A funnel plot was generated to identify publication bias. Two authors appraised studies quality and extracted data independently. This work has been reported according with preferred reporting items for systematic reviews and meta-analyses and assessing the methodological quality of systematic reviews. Statistical analysis was conducted using Review Manager 5.3 software. Risk ratio (RR) with 95% confidence intervals (CI) was calculated and analyzed.

RESULTS

Seven studies (N = 1487 participants) were included in this systematic review, and 6 randomized, controlled trials (N = 1237 participants) were included in the meta-analysis. Comparing with the control groups, the Enterococcus faecium groups had a significant decline in the incidence of NEC Bell stage II or higher (RR: 0.3138, 95% CI: 0.1983-0.4965; P < .00001; 6 studies, n = 1237) and infection (RR: 0.4818, 95% CI: 0.2950-0.7869; P = .004; 3 studies, n = 710).

CONCLUSIONS

Enterococcus faecium is effective and safe in preventing NEC (Bell stage II or higher) in preterm infants. But all studies included came from China. The dosages and durations of taking Enterococcus faecium were various.

A pilot study to disentangle the infant gut microbiota composition and identification of bacteria correlates with high fat mass

Background: At birth, the human intestine is colonized by a complex community of microorganisms known as gut microbiota. These complex microbial communities that inhabit the gut microbiota are thought to play a key role in maintaining host physiological homeostasis. For this reason, correct colonization of the gastrointestinal tract in the early stages of life could be fundamental for human health. Furthermore, alterations of the infant microbiota are correlated with the development of human inflammatory diseases and disorders. In this context, the possible relationships between intestinal microbiota and body composition during infancy are of great interest. Methods: In this study, we have performed a pilot study based on 16S rRNA gene profiling and metagenomic approaches on repeatedly measured data on time involving a cohort of 41 Italian newborns, which is aimed to investigate the possible correlation between body fat mass percentage (FM%) and the infant gut microbiota composition. Results and conclusion: The taxonomical analysis of the stool microbiota of each infant included in the cohort allowed the identification of a specific correlation between intestinal bacteria, such as Bifidobacterium and Veillonella, and the increase in FM%. Moreover, the analysis of the infant microbiome's metabolic capabilities suggested that the intestinal microbiome functionally impacts the human host and its possible influence on host physiology.

Dedifferentiated fat cells administration ameliorates abnormal expressions of fatty acids metabolism-related protein expressions and intestinal tissue damage in experimental necrotizing enterocolitis

Neonatal necrotizing enterocolitis (NEC) is a serious disease of premature infants that necessitates intensive care and frequently results in life-threatening complications and high mortality. Dedifferentiated fat cells (DFATs) are mesenchymal stem cell-like cells derived from mature adipocytes. DFATs were intraperitoneally administrated to a rat NEC model, and the treatment effect and its mechanism were evaluated. The NEC model was created using rat pups hand fed with artificial milk, exposed to asphyxia and cold stress, and given oral lipopolysaccharides after cesarean section. The pups were sacrificed 96 h after birth for macroscopic histological examination and proteomics analysis. DFATs administration significantly improved the survival rate from 25.0 (vehicle group) to 60.6% (DFAT group) and revealed a significant reduction in macroscopical, histological, and apoptosis evaluation compared with the vehicle group. Additionally, the expression of C-C motif ligand 2 was significantly decreased, and that of interleukin-6 decreased in the DFAT group. DFAT administration ameliorated 93 proteins mainly related to proteins of fatty acid metabolism of the 436 proteins up-/down-regulated by NEC. DFATs improved mortality and restored damaged intestinal tissues in NEC, possibly by improving the abnormal expression of fatty acid-related proteins and reducing inflammation.

Extreme prematurity and perinatal risk factors related to extremely preterm birth are associated with complex patterns of regional brain volume alterations at 10 years of age: a voxel-based morphometry study

Objective

Structural brain volumetric differences have been investigated previously in very preterm children. However, children born extremely preterm, at the border of viability, have been studied to a lesser degree. Our group previously analyzed children born extremely preterm at term using voxel-based morphometry. In this study, we aimed to examine regional gray and white matter differences for children born extremely preterm derived from the same cohort during childhood. We also aimed to explore the effect of perinatal risk factors on brain volumes in the same group.

Methods

At 10 years of age, 51 children born extremely preterm (before 27 weeks and 0 days) and 38 term-born controls with high-quality 3.0 Tesla magnetic resonance images were included. Statistical analyses using voxel-based morphometry were conducted on images that were normalized using age-specific templates, modulated, and smoothed. Analyses were also performed in stratified groups of children born extremely preterm in the absence or presence of perinatal risk factors that have previously been shown to be associated with volumetric differences at term.

Results

We found volumetric decreases in gray and white matter in the temporal lobes, gray matter decreases in the precuneus gyri, and white matter decreases in the anterior cingulum for children born extremely preterm (all p < 0.001, and p_fwe < 0.05). Gray and white matter increases were predominantly observed in the right posterior cingulum and occipital lobe (all p < 0.001, and p_fwe < 0.05). Of the examined perinatal risk factors, intraventricular hemorrhage grades I-II compared with no intraventricular hemorrhage and patent ductus arteriosus ligation compared with no treated patent ductus arteriosus or patent ductus arteriosus treated with ibuprofen led to volumetric differences at 10 years of age (all p < 0.001, and p_fwe < 0.05).

Conclusions

Children born extremely preterm exhibit volumetric alterations in a pattern overlapping that previously found at term, where many regions with differences are the main hubs of higher order networks. Some, but not all, risk factors known to be associated with structural alterations at term were associated with alterations at 10 years of age.

Women with preeclampsia exposed to air pollution during pregnancy: Relationship between oxidative stress and neonatal disease - Pilot study

Oxidative imbalance as a pathophysiological mechanism has been reported as an adverse outcome in pregnant women who develop preeclampsia and in their newborns. Furthermore, emerging evidence suggests the same mechanism by which air pollutants may exert their toxic effects. Therefore, the objective of the study was to evaluate the biomarkers of oxidative stress and their relationship with neonatal disease in premature newborns from mothers with preeclampsia exposed to air pollution during pregnancy. The data of air pollutants (PM_2.5, PM₁₀ and ozone) were collected at fixed monitoring stations. Oxidative and antioxidant status markers were obtained through special techniques in women with preeclampsia and in umbilical cord blood of their premature newborns. The oxidative stress markers were significantly higher in women with preeclampsia and their newborns who were exposed to higher levels of ambient air pollutants in the first and second trimester of pregnancy. Neonatal diseases are associated with preeclampsia in pregnancies, specifically intrauterine growth restriction (IUGR) and necrotizing enterocolitis (NEC). A significant correlation was identified in the levels of prooxidant agents and antioxidant enzyme activity in the presence of neonatal diseases associated with preeclampsia. There is increased oxidative damage in both the maternal and fetal circulation in women who develop preeclampsia exposed to air pollution during pregnancy. Therefore, these pregnancies complicated by preeclampsia have a greater adverse outcome as neonatal disease in the preterm infant.

Association of umbilical venous catheters vs peripherally inserted central catheters with death or severe intraventricular hemorrhage among preterm infants < 30 weeks: A randomized clinical trial

BACKGROUND

Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs) are routinely inserted in preterm infants for total parenteral nutrition and medications. We aimed to examine whether the rates of severe intraventricular hemorrhage (IVH) or death vary among preterm infants receiving UVCs compared to PICCs.

METHODS

This randomized controlled trial included preterm infants <  30 weeks gestation assigned after birth to either UVC placement group or PICC group.

RESULTS

A total of 233 preterm infants (117 infants in UVC group, 116 infants in PICC group) were randomized and collected data was available for intention-to-treat analysis. There were no differences in baseline population characteristics. Severe IVH occurred in 16 infants (13.6%) in the UVC group and 11(9.5%) in the PICC group (risk difference [RD], 4.1% [5% CI, -4 to 12.3]; P = 0.42). The incidence of death before 28 days of life did not differ significantly between groups (10 [8.5% ] in UVC vs 6 [5.1%] in PICC; RD, 3.4% [95% CI, -3.0 to 9.84]; P = 0.44). Seventeen percent (20/117) of the UVC group died or developed severe IVH compared with 12% (14/116) of the PICC group (risk difference, 5% [95% CI, -4.01 -14.06]; P = 0.36). The incidence of necrotizing enterocolitis (NEC) was significantly higher in the UVC group infants than in the PICC group infants (7.7% vs. 1.7%); p = 0.03.

CONCLUSIONS

The incidence of severe IVH or death did not differ significantly among preterm m infants <  30 weeks gestation subjected to UVC or PICC placement. Early inotropic support was a significant risk factor for the development of severe IVH. UVC maybe an additional risk factor for the development of NEC, but further research is required to validate this finding.

Survival and Neurodevelopmental Outcome of Extremely-Low-Birth-Weight Infants at One Year of Age-A Prospective, Descriptive Study

OBJECTIVES

To study the survival rates at discharge and neurodevelopmental outcome at 1 y of corrected age (CA) of extremely-low-birth-weight ELBW neonates.

METHODS

This prospective, descriptive study was conducted in a tertiary care level III extramural NICU of a teaching hospital. Forty-nine extremely-low-birth-weight (ELBW) neonates were enrolled in the study from July 2017 to June 2018. Baseline demographic data, morbidities during NICU stay, and survival at discharge for the enrolled neonates were recorded. The enrolled infants were followed up to 1 y of CA at three-monthly intervals. During the follow-up, anthropometry, developmental screening by Denver Developmental Screening Test (DDST), and tone assessment by Amiel-Tison scale were done. Developmental Assessment Scale for Indian Infants (DASII) was administered at CA of 12 mo.

RESULTS

Thirty-seven (75.5%) neonates survived to discharge. Survival rate of neonates with birth weight > 750 g and with gestational age ≥ 26 wk was 90.2% and 85.7%, respectively. Amongst those < 750 g or < 26 wk (n = 8), none survived. Abnormal developmental quotient (DQ < 70%) was seen in 6 infants out of 33 infants (18.1%) followed at 1 y of CA.

CONCLUSION

Overall, 3/4^th of ELBW infants survived to discharge and 80% of those who were followed up at 1 y of CA had normal neurodevelopmental outcome. However, survival rates of neonates born at < 26 wk and/or with birth weight < 750 g  were less and needs to be improved.

Fecal Calprotectin Levels Dynamics in Newborns with High-Risk of Necrotizing Enterocolitis

Background. Necrotizing enterocolitis (NEC) is severe gastrointestinal disease in newborns, its early clinical symptoms are nonspecific. Fecal сalprotectin (Cp) is considered as one of the early biomarkers of NEC, thus, its use in newborns is poorly known.

Objective. The aim of the study is to evaluate clinical significance of fecal Cp measuring as an early NEC marker in newborns. Methods. The prospective cohort observational study included high-risk newborns (gestational age (GA) ˂ 33 weeks and/or body weight ˂ 1500 g) and moderate risk newborns (GV≥ 33 weeks at suspicion on NEC) of NEC admitted to the neonatal intensive care unit on the 1st day of life. The Cp level was studied via immune colorimetric method on the 3rd and 7th days of life in high-risk children and in all children at NEC manifestation. All patients were divided into 2 main subgroups after the end of the follow-up period: newborns with developed NEC (a) and children without NEC (b). Obtained Cp values were compared between these subgroups.

Results. There were no statistically significant differences in Cp levels at the 3rd and 7th days of life in the high-risk group of children with NEC and without NEC. However, it was noted that children without NEC showed a decrease in Cp levels on the 7th day, while children with NEC manifestation, indeed, had increased levels. Cp levels did not differ in the moderate risk group.

Conclusion. Single measurement of Cp level in newborns of any GA is uninformative towards the NEC prognosis and diagnosis. However, evaluation of the Cp level dynamics at the 7th day of life compared to the 3rd day of life may be considered as a promising non-invasive method for prognosis of NEC manifestation in premature infants (GA<33 weeks). 

Therapeutic Potential of Gut Microbiota and Its Metabolite Short-Chain Fatty Acids in Neonatal Necrotizing Enterocolitis

Short chain fatty acids (SCFAs), the principle end-products produced by the anaerobic gut microbial fermentation of complex carbohydrates (CHO) in the colon perform beneficial roles in metabolic health. Butyrate, acetate and propionate are the main SCFA metabolites, which maintain gut homeostasis and host immune responses, enhance gut barrier integrity and reduce gut inflammation via a range of epigenetic modifications in DNA/histone methylation underlying these effects. The infant gut microbiota composition is characterized by higher abundances of SCFA-producing bacteria. A large number of in vitro/vivo studies have demonstrated the therapeutic implications of SCFA-producing bacteria in infant inflammatory diseases, such as obesity and asthma, but the application of gut microbiota and its metabolite SCFAs to necrotizing enterocolitis (NEC), an acute inflammatory necrosis of the distal small intestine/colon affecting premature newborns, is scarce. Indeed, the beneficial health effects attributed to SCFAs and SCFA-producing bacteria in neonatal NEC are still to be understood. Thus, this literature review aims to summarize the available evidence on the therapeutic potential of gut microbiota and its metabolite SCFAs in neonatal NEC using the PubMed/MEDLINE database.

Epigenetic Immune Cell Counting to Analyze Potential Biomarkers in Preterm Infants: A Proof of Principle in Necrotizing Enterocolitis

Epigenetic immune cell counting is a DNA (de)methylation-based technique which can be used to quantify lymphocyte subsets on dried blood spots (DBS). The foregoing techniques allow for a retrospective investigation of immune cell profiles in newborns. In this study, we used this technique for determining lymphocyte subcounts as a potential biomarker for necrotizing enterocolitis (NEC). We investigated whether this technique can be implemented in the field of neonatology, by testing whether regulatory T cell (Treg) levels are pre-existently low in preterms with NEC. Newborn screening (NBS) cards from 32 preterms with NEC and 32 age- and weight-matched preterm controls, and 60 healthy term newborns, were analyzed. Relative and absolute cell counts were determined for CD3+, CD4+, CD8+, Th17, and Treg T cells. For both relative and absolute cell counts of CD3+, CD4+, CD8+, and Th17 T cells, significant differences were found between healthy term controls and both preterm groups, but not between preterm groups. For Tregs, no significant differences were found in either relative or absolute counts between any of the newborn groups. This study demonstrates the principle of epigenetic immune cell counting to analyze lymphocyte subsets in preterm neonates.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes

BACKGROUND

Chorioamnionitis is a risk factor for fetal and neonatal outcomes. Therefore, predicting histological chorioamnionitis (HCA) and neonatal outcomes using clinical parameters could be helpful in management and preventing morbidities.

OBJECTIVE

To determine if parameters of clinical chorioamnionitis (CCA) would be associated with HCA and neonatal outcomes.

STUDY DESIGN

In this cohort study using a retrospective design, we analyzed the performance of signs of CCA in predicting HCA, and neonatal outcomes. Data were extracted from the electronic health record for all neonates with documented CCA delivered at our institution from 2011 to 2016. We compared our findings based on the old ACOG definition of CCA and the new definition released in 2017 - maternal fever plus any of fetal tachycardia, maternal leukocytosis, and purulent vaginal discharge. Maternal tachycardia and uterine tenderness were removed from the new criteria. Neonatal laboratory samples on admission, 12 h and 24 h were used to define the three time points of neonatal suspected sepsis.

RESULTS

There were 530 mothers-infant dyads with chorioamnionitis. Seventy-three were preterm, and 457 were term. Eighty-eight percent of the preterm mothers had CCA, and HCA was present in 62.5% of 72 preterm placentas. Preterm infants with placental HCA significantly had lower birth weight, gestational age, placental weight, and more infants with lower 5-minute Apgar scores, compared to those with no HCA. In preterm infants, maternal urinary tract infection was significantly associated with decreased odds for HCA (OR 0.22, CI 0.10 - 0.71). More preterm babies with suspected sepsis criteria at the 3 time points had HCA (all p ≤ .01). In the term cohort, 95.4% and 65.6% had CCA and HCA, respectively. In term infants (n = 457), maternal leukocytosis (p = .002) and prolonged rupture of membranes (PROM; p = 002) were associated with HCA. Suspected sepsis was associated with PROM (p = .04), HCA (p = .0001), and maternal leukocytosis (p ≤ .05) in at least 1 of the 3 time points.

CONCLUSION

Though maternal leukocytosis was significantly associated with the presence of HCA in the term cohort, there were no CCA criteria that accurately predicted presence of HCA in either the preterm or the term infants.

Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital

BACKGROUND

Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes.

PURPOSE

To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital.

METHODS

The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization.

FINDINGS

NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention.

IMPLICATIONS FOR PRACTICE

Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals.

IMPLICATIONS FOR RESEARCH

Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

Association of prematurity with complications and failure to rescue in neonatal surgery

BACKGROUND

The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates.

METHODS

National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR.

RESULTS

Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33-36 weeks, 15%; 29-32 weeks, 30%; 25-28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38-4.41]) and high-risk (OR 2.27, 95% CI [1.33-3.87]) procedures. A lone inflection point for FTR was identified at 31-32 weeks with cubic spline analysis.

CONCLUSIONS

The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31-32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Incidence, Risk Factors and Prediction of Secondary Hyperparathyroidism in Preterm Neonates under 32 Weeks’ Gestational Age

In preterm newborns, secondary hyperparathyroidism (HPTH) is an underdiagnosed and undertreated entity. Its detection in the context of metabolic bone mineral disease (MBD) screening programs may be important to guide nutritional treatment. We designed a retrospective cohort study to determine the incidence of HPTH in very premature infants. As secondary objectives, we studied the risk factors, morbidities, and biochemical alterations associated with HPTH. A total of 154 preterm newborns ≤32 weeks gestational age (GA) were included. Of these, 40.3% (n = 62) presented with HPTH. In the multivariate analysis, independent risk factors for HPTH were cesarean section (OR: 4.00; 95% CI: 1.59–10.06), oxygen during resuscitation (OR: 3.43; 95% CI: 1.09–10.81), invasive mechanical ventilation (OR: 3.56; 95% CI: 1.63–7.77) and anemia requiring transfusion (OR: 2.37; 95% CI: 1.01–5.57). Among the analytical variables, serum calcium (OR: 0.53; 95% CI: 0.29–0.97), serum phosphate (OR: 2.01; 95% CI: 1.39–2.92), vitamin D (OR: 0.96; 95% CI: 0.93–1), and the calcium/creatinine ratio in urine (OR: 0.05; 95% CI: 0.01–0.28) were independently associated with HPTH. The simplified predictive model included GA and calcium/creatinine ratio in urine and demonstrated an AUC of 0.828. We concluded that HPTH is a frequent entity among very premature infants and that further studies are required to determine the role of HPTH in MBD and the clinical applicability of prediction models.

Effect of a Multi-Strain Probiotic on the Incidence and Severity of Necrotizing Enterocolitis and Feeding Intolerances in Preterm Neonates

Background: Necrotizing enterocolitis (NEC) is a multifactorial disease, causing inflammation of the bowel. The exact root of NEC is still unknown, but a low weight and gestational age at birth are known causes. Furthermore, antibiotic use and abnormal bacterial colonization of the premature gut are possible causes. Premature neonates often experience feeding intolerances that disrupts the nutritional intake, leading to poor growth and neurodevelopmental impairment. Methods: We conducted a double-blind, placebo-controlled, randomized clinical trial to investigate the effect of a multi-strain probiotic formulation (LabinicTM) on the incidence and severity of NEC and feeding intolerances in preterm neonates. Results: There were five neonates in the placebo group who developed NEC (Stage 1A−3B), compared to no neonates in the probiotic group. Further, the use of probiotics showed a statistically significant reduction in the development of feeding intolerances, p < 0.001. Conclusion: A multi-strain probiotic is a safe and cost-effective way of preventing NEC and feeding intolerances in premature neonates.

Pneumatosis coli in preterm neonates: Can they be managed more conservatively to maintain the intestinal milieu?

Necrotising enterocolitis (NEC) is a severe gastrointestinal disease mostly in premature infants due to intestinal necrosis. The aetiology of NEC is multifactorial and includes gut immaturity, intestinal dysbiosis and exaggerated intestinal mucosal reactivity to microbial ligands. Radiographic evidence of pneumatosis intestinalis has been a critical feature for diagnosing NEC Bell stage ≥IIA and recommended treatment includes prolonged antibiotics (7-14 days) while off enteral feeds. Pneumatosis coli (Pcoli), a mild or benign form of NEC, is characterised by pneumatosis limited to the colon in an infant having haematochezia, negative septic screening and no systemic signs. We report two healthy preterm infants with haematochezia and colonic pneumatosis while on breast milk feeds. The sepsis screen was negative. A brief period of antibiotics and gut rest led to the spontaneous resolution of haematochezia and colonic pneumatosis, facilitating early enteral feeds. This case report emphasises the need to differentiate NEC from benign Pcoli.

Body Weight Gain Status during the Incubator Weaning Process in Very Low Birth Weight Premature Infants

Incubator care is essential for premature infants during early hospitalization. As the infants’ conditions improve, incubator weaning becomes necessary. This retrospective study aimed to evaluate the effect of body weight gain and status of intake-calorie gain on the incubator weaning process for very low birth weight (VLBW) premature infants. The study included 127 VLBW premature neonates. We analyzed data on clinical characteristics potentially associated with the weaning period and the end-weaning body weight (EWBW), including body weight gain status, intake-calorie gain status, and disease conditions. The neonates were weaned from the incubators at a mean postmenstrual age (PMA) of 35.1 ± 1.3 weeks; postnatal days, 37.7 ± 18.2 days; and body weight, 1882.8 ± 157.1 g. The total weaning period was 3.5 ± 3.1 days. Regarding the weaning period, there was a strong positive relationship only in the end-weaning PMA and the daily body weight within 3 days before incubator weaning. Further, regarding the factors associated with EWBW, only the end-weaning PMA and necrotizing enterocolitis had a significant positive impact. Body weight gain and the status of intake-calorie gain showed no association with either the weaning period or the EWBW and, thus, were not related to the incubator weaning process.

Ileal lactobezoar in extreme premature infant complicated by intestinal perforation: A case report

INTRODUCTION AND IMPORTANCE

Lactobezor is a rare complication that has been reported more in the stomach, however it may be located anywhere in the intestine.

CASE REPORT

Reported here, is a case of ileal lactobezoar which was complicated by perforation and was mimicking necrotizing enterocolitis in presentation, ex preterm (26 weeks) male infant who presented at day of life 18th (2 days after BM fortification) with hemodynamic instability and intestinal perforation, which was diagnosed by Abdominal X-ray and Ultrasound necessitating urgent laparotomy.

CLINICAL DISCUSSION

Laparotomy revealed an area of ileal perforation and an inspissated mass which was confirmed to be lactobezoar by pathology, ileostomy was performed. The baby had an acute postoperative status of hypovolemic shock which was managed clinically, then was restarted on feeds, and the stoma was reversed 9 weeks later.

CONCLUSION

Lactobezoar, although rare, but numbers increased especially with the rise in numbers of extremely preterm infants worldwide, it most commonly presents later in life but in some cases, such as our case it may happen in 1st 2-3 weeks after birth and may cause significant complications as perforation making its differentiation from common GI problems in neonates as NEC more challenging.

The NICU Antibiotics and Outcomes (NANO) trial: a randomized multicenter clinical trial assessing empiric antibiotics and clinical outcomes in newborn preterm infants

Background

Early-onset sepsis is an important cause of neonatal morbidity and mortality in the preterm population. Infants perceived to be at increased risk for early-onset sepsis are often treated empirically with broad-spectrum antibiotics while awaiting confirmatory blood cultures, despite an overall incidence of early-onset sepsis of 2–3% among extremely-low-birthweight (ELBW) infants. Recent observational studies associate perinatal antibiotic use with an increased incidence of necrotizing enterocolitis, late-onset sepsis, and mortality among ELBW infants. Given currently available data and variability in clinical practice, we designed a prospective multi-institutional randomized controlled trial to determine the safety of early antibiotic use in ELBW infants.

Methods

The NICU Antibiotics and Outcomes (NANO) trial is a multicenter, double-blinded, randomized controlled trial. A sample of 802 ELBW preterm infants will undergo web-based stratified block randomization to receive empiric antibiotics (EA; ampicillin and gentamicin) or placebo during routine evaluation for early-onset sepsis. Participating sites will use preexisting institutional protocols for antibiotic dosage and duration. Infants born at participating sites with a gestational age of 29 weeks or less are eligible for enrollment. Exclusion criteria include maternal intrauterine infection, hemodynamic or respiratory instability, delivery by caesarean section for maternal indications without labor or prolonged rupture of membranes, and prior administration of antibiotics. The primary outcome is the composite incidence of necrotizing enterocolitis, late-onset sepsis, or death during participants’ index hospitalization. Maternal and infant samples will be collected longitudinally and assessed for differences in microbiome composition and diversity.

Discussion

The NANO trial is designed to compare the rate of adverse outcomes of EA use at birth versus placebo in ELBW preterm infants. If EA at birth worsens clinical outcomes, then the results of the trial may help providers decrease antibiotic utilization in the NICU and subsequently decrease the incidence of complications associated with early antibiotic use in ELBW infants. If we instead find that EA improve outcomes, then the trial will validate a longstanding clinical practice that has not previously been supported by high-quality data. Future studies will assess long-term clinical and microbial outcomes in infants who received empiric antibiotics following delivery.

Trial registration

Trial registration data: June 25, 2019 NCT03997266.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06352-3.

Clostridium perfringens-Induced Necrotic Diseases: An Overview

Clostridium perfringens, a prevalent Gram-positive bacterium, causes necrotic diseases associated with abundant life loss and economic burdens of billions of USD. The mechanism of C. perfringens-induced necrotic diseases remains largely unknown, in part, because of the lack of effective animal models and the presence of a large array of exotoxins and diverse disease manifestations from the skin and deep tissues to the gastrointestinal tract. In the light of the advancement of medical and veterinary research, a large body of knowledge is accumulating on the factors influencing C. perfringens-induced necrotic disease onset, development, and outcomes. Here, we present an overview of the key virulence factors of C. perfringens exotoxins. Subsequently, we focus on comprehensively reviewing C. perfringens-induced necrotic diseases such as myonecrosis, acute watery diarrhea, enteritis necroticans, preterm infant necrotizing enterocolitis, and chicken necrotic enteritis. We then review the current understanding on the mechanisms of myonecrosis and enteritis in relation to the immune system and intestinal microbiome. Based on these discussions, we then review current preventions and treatments of the necrotic diseases and propose potential new intervention options. The purpose of this review is to provide an updated and comprehensive knowledge on the role of the host–microbe interaction to develop new interventions against C. perfringens-induced necrotic diseases.

Incidence, Risk Factors, and Outcomes of Acute Kidney Injury in Necrotizing Enterocolitis: A Prospective Single-Center Study

Necrotizing enterocolitis (NEC) is a significant cause of morbidity and mortality in the neonatal intensive care unit (NICU). Acute kidney injury (AKI) is considered to be one of the most well-established risk factors for mortality in neonates. The aim of this work was to study the incidence of AKI in neonates with NEC and to determine the associated conditions, risk factors, and outcomes. We carried out this prospective cross-sectional study on 104 neonates treated for NEC from September 2015 to September 2019. Diagnoses of AKI were made using the neonatal modified Kidney Disease: Improved Global Outcome criteria. AKI occurred in 63 neonates (61%), with 32 at Stage 1 (31%), 20 at Stage 2 (19%), and 11 at Stage 3 (11%), including three requiring dialysis. Vancomycin use and positive blood culture were risk factors for developing AKI in our NEC neonates (odds ratio: 2.47 and 2.41; P = 0.03 and 0.04, respectively). Neonates with AKI had a higher mortality rate (47.6% vs. 26.8 %, P = 0.03) and an increased length of stay (LOS) (69.8 days vs. 53.9 days, P <0.01) than the non-AKI group. Surgical intervention was required in 11 (10.5%) of our neonates. We concluded that AKI occurs in about 60% of neonates with NEC and is associated with higher mortality and LOS in the NICU. Therefore, it is very important to identify and manage all neonates who are at a high risk of developing AKI as quickly as possible.

Advances in our understanding of the molecular pathogenesis of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a multifactorial and complex disease. Our knowledge of the cellular and genetic basis of NEC have expanded considerably as new molecular mechanisms have been identified. This article will focus on the current understanding of the molecular pathogenesis of NEC with a focus on the inflammatory, immune, infectious, and genetic mechanisms that drive disease development.

Role of the antioxidant pathway in the healing of peptic ulcers induced by ischemia-reperfusion in male and female rats treated with Eugenia punicifolia

Ischaemia and reperfusion (I/R)-induced gastrointestinal disorders are caused by free radicals, resulting in organ damage and functional disarrangement. This study aimed to investigate the healing effects of hydroalcoholic extracts from the leaves of Eugenia punicifolia (Kunth) DC. (HEEP) in male and female Wistar rats with I/R-induced peptic injuries, and the role of antioxidants in improving this response. After I/R-induced gastric and duodenal injuries, male and female [intact (INT) and ovariectomized (OVZ)] rats were orally treated with HEEP for 6 days. Biochemical analysis was used to determine the catalase (CAT), superoxide dismutase (SOD), and myeloperoxidase (MPO) activities, as well as malondialdehyde and reduced glutathione levels, to measure the gastric and duodenal healing process. Six days of HEEP treatment significantly decreased the I/R-induced gastric [male (73.68%), INT (52.83%), and OVZ (43.13%)] and duodenal damage [male (57.03%), INT (56.04%), and OVZ (54.83%)] in all groups. In OVZ rats, the healing effect of HEEP occurred because of the increased activity of SOD (2x) and CAT (1.16x) in the gastric mucosa. In the duodenal mucosa of INT rats, the extract reduced MPO (20.83%) activity. The 6-day HEEP treatment improved the healing of I/R-induced peptic ulcer injury, with the system acting differently in males and females. The antioxidant system is an important component of the HEEP activity during post-I/R mucosal recovery. This result revealed the importance of antioxidant compounds in minimizing the severity of I/R-related events.

A quality improvement initiative to standardize time to initiation of enteral feeds after non-surgical necrotizing enterocolitis using a consensus-based guideline

BACKGROUND

Recent evidence demonstrates that earlier feeding may be beneficial after non-surgical necrotizing enterocolitis (NEC). We aimed to decrease time to reach full enteral feeds by 20% post-NEC by standardizing time to reinitiate feeds.

METHODS

We implemented a consensus-based guideline for earlier feeding post-NEC. Outcome measures included days to initiate enteral feeds and reach full enteral feeds. Central venous line days and length of stay were also evaluated. Balancing measures were NEC recurrence and post-NEC stricture. Statistical analysis used process control methodology and standard comparison statistical testing.

RESULTS

Average days infants with Stage II NEC began feeding decreased from 9.4 to 5.1 days and average days to reach full feeds was decreased by 35% from 24.0 to 15.7 days. We observed no change in our balancing measures.

CONCLUSION

A multidisciplinary consensus-based NEC earlier feeding guideline decreased time to reach full enteral feeds and reduced central line days without adverse events.

Incidence, Predictors and Outcomes of Noninvasive Ventilation Failure in Very Preterm Infants

Non-invasive ventilation (NIV) is now considered the first-line treatment for respiratory distress syndrome in preterm infants. We aimed to evaluate the rates of non-invasive ventilation failure rate in very preterm infants, as well as to identify its predictors and associated outcomes. We designed a single-center retrospective cohort study including infants ≤32 weeks gestational age and ≤1500 g. The NIV failure was defined as the need for intubation at <72 h of life. After applying inclusion and exclusion criteria, 154 patients were included in the study, with a mean GA of 29.7 ± two weeks. The NIV failure rate was 16.2% (n = 25) and it was associated with lower bronchopulmonary dysplasia (BPD)-free survival (OR 0.08; 95% CI 0.02−0.32) and higher incidence of intraventricular hemorrhage > II (OR 6.22; 95% CI 1.36−28.3). These infants were significantly smaller in GA and weight. Higher FiO2 during resuscitation (OR 1.14; 95% CI 1.06−1.22) and after surfactant administration (OR 1.17; 95% CI 1.05−1.31) represented independent risk factors for NIV failure. In conclusion, NIV failure is frequent and it could be predicted by a higher oxygen requirement during resuscitation and a modest response to surfactant therapy. Importantly, this NIV failure is associated with worse clinical outcomes.

The impact of a multifaceted quality improvement program on the incidence of necrotizing enterocolitis in very low birth weight infants

BACKGROUND

Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease which mostly occurs in very low birth weight (VLBW) infants. In addition to decreasing gestational age (GA) or birth weight (BW), artificial formula, delayed initiation or rapidly advanced feeding, severe anemia and systemic infections were associated with NEC. Several studies demonstrated that breast milk, standardized feeding advancement regimens and treatment of anemia are associated with less incidence of NEC. It is not known if including all these interventions in one multifaceted program will lead to significant reduction in NEC.

METHODS

The NICU team at The George Washington University Hospital created a multifaceted interdisciplinary quality improvement project to tackle several aspects of NEC prevention that addressed researched risk factors for NEC. The program was made of four quality improvement protocols: 1) Standardized Structured Feeding Program, 2) Feeding Intolerance Management Algorithm, 3) Enteral Osmolality Control Tool, and 4) Packed Red Blood Cell (RBC) Standardized Transfusion Protocol. This time-series, quasi experimental study design examined the differences in the incidence of NEC between infants with BW < 1500 g who were admitted to the GW Hospital NICU before and after the program implementation.

RESULTS

Data from 408 VLBW infants were included in the study. Although not statistically significant, there was a decreasing trend of NEC incidence in the post-implementation group (n = 199) compared to the pre-implementation group (n = 209), (3.5% vs. 5.3%, p = 0.88). The trend in the incidence of NEC declined further after the introduction of RBC transfusion protocol which was introduced ten month after starting the other elements of the program.

CONCLUSION

Integration of the multifaceted quality improvement program may be associated with a decline in the occurrence of NEC. Further analysis with a larger sample size is required to determine if the changes seen are statistically significant.

Nonfermenting, Gram-Negative Bacilli Causing Neonatal Sepsis in Odisha, India: Four-Year Surveillance

Introduction

In India, blood culture-positive sepsis results in mortality in 33%-35% of affected neonates. Nonfermenting Gram-negative bacilli (NFGNB), particularly Acinetobacter baumannii and Burkholderia cepacia commonly cause hospital-acquired infection.

Materials and methods

We performed a subgroup analysis as part of a prospective study conducted in a neonatal intensive care unit in a tertiary care hospital in Odisha, India, between January 2017 and December 2020. Neonates with blood culture-positive sepsis caused by NFGNB were enrolled in this study. Demographic characteristics of the neonates, clinical features of sepsis, complications, need for supportive care, and blood culture sensitivity patterns were recorded and analyzed.

Results

A total of 168 organisms were isolated in blood cultures during our study period, of which 48 (29%) were NFGNB species. Among these 48 species, A. baumannii (37.5%) and B. cepacia (33.3%) were the most common NFGNB in our study. Neonates with sepsis commonly exhibited feeding intolerance (64.5%), circulatory insufficiency that necessitated vasopressor treatment (54.1%), disseminated intravascular coagulopathy (35.4%), seizures (33.3%), and the need for respiratory support (56.2%). NFGNB were multidrug-resistant (MDR) in 70.8% of cases, and 93.7% of B. cepacia and 55.5% of A. baumannii were MDR.

Conclusions

A. baumannii and B. cepacia are NFGNB commonly isolated in neonatal cases of blood culture-positive sepsis. The prevalence of MDR NFGNB sepsis is gradually increasing, which poses a threat to neonates. Strict aseptic precautions and antibiotic stewardship are thus mandatory in perinatal practice.

Enteric Nervous System in Neonatal Necrotizing Enterocolitis

BACKGROUND

The pathophysiology of necrotizing enterocolitis (NEC) is not clear, but increasing information suggests that the risk and severity of NEC may be influenced by abnormalities in the enteric nervous system (ENS).

OBJECTIVE

The purpose of this review was to scope and examine the research related to ENS-associated abnormalities that have either been identified in NEC or have been noted in other inflammatory bowel disorders (IBDs) with histopathological abnormalities similar to NEC. The aim was to summarize the research findings, identify research gaps in existing literature, and disseminate them to key knowledge end-users to collaborate and address the same in future studies.

METHODS

Articles that met the objectives of the study were identified through an extensive literature search in the databases PubMed, EMBASE, and Scopus.

RESULTS

The sources identified through the literature search revealed that: (1) ENS may be involved in NEC development and post-NEC complications, (2) NEC development is associated with changes in the ENS, and (3) NEC-associated changes could be modulated by the ENS.

CONCLUSION

The findings from this review identify the enteric nervous as a target in the development and progression of NEC. Thus, factors that can protect the ENS can potentially prevent and treat NEC and post-NEC complications. This review serves to summarize the existing literature and highlights a need for further research on the involvement of ENS in NEC.

Nutritional Factors Associated with Late-Onset Sepsis in Very Low Birth Weight Newborns

BACKGROUND

Delayed onset of minimal enteral nutrition compromises the immune response of preterm infants, increasing the risk of colonization and clinical complications (e.g., late-onset sepsis). This study aimed to analyze associations between late-onset sepsis in very low birth weight infants (<1500 g) and days of parenteral nutrition, days to reach full enteral nutrition, and maternal and nutritional factors.

METHODS

A cross-sectional study was carried out with very low birth weight infants admitted to a neonatal intensive care unit (NICU) of a reference maternity hospital of high-risk deliveries. Data regarding days of parenteral nutrition, days to reach full enteral nutrition, fasting days, extrauterine growth restriction, and NICU length of stay were extracted from online medical records. Late-onset sepsis was diagnosed (clinical or laboratory) after 48 h of life. Chi-squared, Mann-Whitney tests, and binary logistic regression were applied.

RESULTS

A total of 97 preterm infants were included. Of those, 75 presented late-onset sepsis with clinical (n = 40) or laboratory (n = 35) diagnosis. Maternal urinary tract infection, prolonged parenteral nutrition (>14 days), and extrauterine growth restriction presented 4.24-fold, 4.86-fold, and 4.90-fold higher chance of late-onset sepsis, respectively.

CONCLUSION

Very low birth weight infants with late-onset sepsis had prolonged parenteral nutrition and took longer to reach full enteral nutrition. They also presented a higher prevalence of extrauterine growth restriction than infants without late-onset sepsis.

Necrotizing enterocolitis in the preterm: newborns medical and nutritional Management in a Single-Center Study

Necrotizing enterocolitis (NEC) is a typical disorder of preterm newborns, with a high mortality and morbidity rate. The therapeutic and nutritional management of disease depends on several factors. Its prognosis is linked, in addition to the severity of the disease and the need for surgery, to a correct enteral feeding in these patients. This study aims to identify the clinical characteristics of 18 patients with NEC, evaluating the different therapeutic paths undertaken, the type of formula used and the survival rate of this population. Average time of enteral nutrition before the NEC onset was 11,3 ± 11,6 days, with an average fasting period since the onset of 24 ± 18.9 days. 77.8% of patients received surgery and resumed enteral nutrition 17.7 ± 17.9 days after the intervention. The overall survival rate of our cohort was 55.5%. More prospective studies are needed to evaluate the long-term outcomes of survived children with NEC.

Exploring the distribution of grey and white matter brain volumes in extremely preterm children, using magnetic resonance imaging at term age and at 10 years of age

Objectives

To investigate differences in brain volumes between children born extremely preterm and term born controls at term age and at 10 years of age.

Study design

Children born extremely preterm (EPT), up to 26 weeks and 6 days gestational age, in Stockholm between January 1 2004 to March 31 2007 were included in this population-based cohort study. A total of 45 EPT infants were included at term age and 51 EPT children were included at 10 years of age. There were 27 EPT children included at both time points. Two different control groups were recruited; 15 control infants were included at term age and 38 control children at 10 years of age. The primary outcomes were the grey and white matter volumes. Linear regression, adjusted for intracranial volume and sex, was used.

Results

At term age, the extremely preterm infants had significantly smaller grey matter volume compared to the control infants with an adjusted mean difference of 5.0 cm³ and a 95% confidence interval of −8.4 to −1.5 (p = 0.004). At 10 years of age the extremely preterm children had significantly smaller white matter volume compared to the control children with an adjusted mean difference of 6.0 cm³ and a 95% confidence interval of −10.9 to −1.0 (p = 0.010).

Conclusion

Extremely preterm birth was associated with reduced grey matter volume at term age and reduced white matter volume at 10 years of age compared to term born controls.

Necrotizing Enterocolitis in Preterm Infants Born to Mother with COVID-19

Background: The COVID-19 pandemic has had a wide impact on both pregnant women and their babies. Necrotizing enterocolitis (NEC) is a gastrointestinal emergency in neonates with high morbidity and mortality. Objective: This study aims to investigate the incidence of NEC in preterm infants born to mothers with confirmed COVID-19. Methods: This observational study was conducted in neonatal intensive care unit at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, from May 2020 to April 2021. All preterm infants born to mothers with positive COVID-19 based on swab examination were included as study participants. PCR swab examination was performed within 48 hours after birth. The diagnosis of COVID-19 was defined as positive if the swab test result could detect the SARS-CoV-2 virus. The diagnosis of NEC was established by clinical symptoms and confirmed by abdominal radiography. Results: Out of 45 preterm infants included in this study, 6 infants experienced NEC. Factors that were significantly associated with the incidence of NEC included asphyxia and intubated mother. Positive PCR results from the infants alone did not significantly increase the risk of NEC. The combination of asphyxia and intubated mother (Odds Ratio [OR]=10.000, 95% Confidence Interval [CI]=1.056-94.677, P=0.020) and the combination of positive PCR result, asphyxia, and intubated mother (OR=2.438, 95% CI=1.673-3.551, P=0.007) were found to be significantly associated with the incidence of NEC Conclusion: Significant factors associated with the incidence of NEC in preterm infants born to mothers with COVID-19 included asphyxia and intubated mothers prior to delivery. A positive PCR result alone did not significantly increase the risk of NEC.

IL-27 as a potential biomarker for distinguishing between necrotising enterocolitis and highly suspected early-onset food protein-induced enterocolitis syndrome with abdominal gas signs

Background

The initial clinical manifestations and abdominal imaging findings of neonates with necrotising enterocolitis (NEC) and food protein-induced enterocolitis syndrome (FPIES) are sometimes similar; however, their prognosis and therapies are different. We aimed to evaluate the utility of interleukin (IL)-27 as a differentiation marker between NEC and highly suspected early onset (HSEO)-FPIES.

Methods

All samples used in this study were obtained from the neonatal diagnosis centre of Children's Hospital of Chongqing Medical University. In the case-control study, neonates with NEC (n = 13), HSEO-FPIES (n = 9), and jaundice (control, n = 8) were enroled to determine the serum IL-27 levels using commercial enzyme-linked immunosorbent assay (ELISA) kits. In the validation cohort study, the NEC (n = 87), HSEO-FPIES (n = 62), and jaundice (control, n = 54) groups were included to analyse the diagnostic efficiency of IL-27 for discriminating between NEC and HSEO-FPIES using a receiver operating characteristic (ROC) curve.

Findings

In the case-control study, IL-27 levels were higher in the NEC group than in the HSEO-FPIES group (p = 0·005). In the cohort study, the area under the ROC curve (AUC) of IL-27 for differentiating NEC from HSEO-FPIES was 0·878, which was higher than the AUCs of IL-6 (0·761), C-reactive protein (0·800), white blood cell count (0·637), neutrophils (0·765), lymphocytes (0·782), neutrophil to lymphocyte ratio (0·781), and platelet count (0·729).

Interpretation

Serum IL-27 is a novel biomarker that may potentially discriminate NEC from HSEO-FPIES in neonates.

Administration of breast milk cell fractions to neonates with birthweight equal to or less than 1800 g: a randomized controlled trial

Background

Most premature and very low birthweight infants cannot tolerate breast milk feeding in the first few days of life and are deprived of its benefits. This study evaluates the clinical outcomes of administering breast milk cell fractions to neonates with a birthweight of ≤1800 g.

Methods

We conducted a randomized controlled trial on 156 infants in the neonatal intensive care unit of Mahdieh Maternity Hospital in Tehran, Iran, from May 2019 to April 2020. All neonates with a birthweight ≤1800 g were enrolled and divided into intervention and control groups using stratified block randomization. Neonates in the intervention group received the extracted breast milk cell fractions (BMCFs) of their own mother’s milk after being centrifuged in the first 6 to 12 h after birth. The control group received routine care, and breastfeeding was started as soon as tolerated in both groups. Study outcomes were necrotizing enterocolitis (NEC), death, and in-hospital complications.

Results

We divided participants into two groups: 75 neonates in the intervention group and 81 neonates in the control group. The mean birthweight of neonates was 1390.1 ± 314.4 g, and 19 (12.2%) neonates deceased during their in-hospital stay. The incidence of NEC was similar in both groups. After adjustment for possible confounders in the multivariable model, receiving BMCFs were independently associated with lower in-hospital mortality (5 [26.3%] vs. 70 (51.1%]; odds ratio (OR): 0.24; 95% confidence interval [CI] 0.07, 0.86). Also, in a subgroup analysis of neonates with birthweight less than 1500 g, in-hospital mortality was significantly lower in the intervention group (4 [9.5%] vs. 13 [30.2%]; OR: 0.24; 95% CI 0.07, 0.82). There were no differences in major complications such as bronchopulmonary dysplasia and retinopathy of prematurity between the two groups. No adverse effects occurred.

Conclusions

Our research demonstrated a significantly lower mortality rate in neonates (with a birthweight of ≤1800 g) who received breast milk cell fractions on the first day of life. Since this is a novel method with minimal intervention, we are looking forward to developing and evaluating this method in larger studies.

Trial registration

IIranian Registry of Clinical Trials. Registered 25 May 2019, IRCT20190228042868N1.

Epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary hospital in Northern India

AIMS AND OBJECTIVES

To study the epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary care teaching hospital in Northern India.

MATERIALS AND METHODS

Neonates (n = 406) with blood culture positive sepsis were enrolled prospectively over a period of 1 year (February 2018-January 2019). Demographic details, clinical features, microbiological profile, antibiotic sensitivity pattern, treatment, and outcome were recorded.

RESULTS

The mean (±SD) age at presentation was 2.4 (±0.6) days and 2/3rd were males. The mean (±SD) gestation was 35.5 (±3.4) weeks, birth weight was 2215 (±219) g, and 42.4% were preterm. The proportion of neonates with early and late onset sepsis were 69% and 31%, respectively. Predominant isolates were Gram-negative (46.5%), Gram-positive (27.6%) organisms, and yeast (25.9%). Klebsiella pneumoniae (46.5%), Acinetobacter baumannii (17.5%), and Escherichia coli (8%) were common Gram-negative; and coagulase negative Staphylococcus (CONS) (70%), Staphylococcus aureus (13.4%), and Enterococcus (12.5%) were common Gram-positive organisms. Among Gram-negative organisms, the antibiotic sensitivity pattern was ciprofloxacin 45%, cephalosporins 15-40%, aminoglycosides 20-42%, piperacillin-tazobactam 49%, carbapenems 34-51%, tetracyclines 55-70%, doxycycline 55%, chloramphenicol 42%, and colistin 98%; and among Gram-positive organisms were methicillin 30%, clindamycin 52%, vancomycin 100%, teicoplanin 98%, and linezolid 99%. The survival rate was 60.3%. The neonates with Gram-negative sepsis had higher requirement of oxygen, mechanical ventilation, and vasoactive drugs; had more complications; and lower survival (50.3% vs. 72.3%, p= .003) when compared to Gram-positive sepsis.

CONCLUSIONS

Gram-negative organisms were commonest cause of neonatal sepsis, had low sensitivity to commonly used antibiotics, and associated with poor outcome.

Surgical Versus Medical Management of Necrotizing Enterocolitis With and Without Intestinal Perforation: A Retrospective Chart Review

Background

Necrotizing enterocolitis (NEC) is a debilitating disease that predominantly afflicts premature neonates, although it can also affect term neonates. The clinical features of the ailment vary widely and range from transient feed intolerance to life-threatening complications such as septicemia and disseminated intravascular coagulation. While surgery is usually only reserved for severe cases, such as those presenting with intestinal perforation, the role of surgical management in cases of NEC without perforation remains elusive.

Methods

A retrospective chart review of patients, three years in duration, was conducted and studied confirmed cases of NEC. The clinical presentations studied included cases of NEC with pneumatosis intestinalis, fixed bowel loop, pneumoperitoneum, and abdominal wall erythema. The patients were divided with regards to their intestinal perforation status and with pertinence to the treatment modality employed (medical or surgical). The results in either group were eventually analyzed in terms of the overall survival rate.

Results

A total of 48 patients were included in the study, of which 79.16% presented without perforation and 20.83% with perforation. Of the study participants included, 26 were females and 22 were males. Pertinently, no gender predominance was appreciated. In patients without perforation, medical management was noted to boast a lower mortality rate when compared with surgical intervention (15.6% vs 50.0%, respectively). In patients with perforation, the overall mortality was noted to hover at 50.0%, which was higher than that encountered in the non-perforation group.

Conclusion

In patients with NEC without perforation, surgical treatment confers no comparative therapeutic advantage when compared with medical management alone. Conservative management with broad-spectrum antibiotics including metronidazole yields equally favorable outcomes in such cases.

Necrotising enterocolitis in newborns receiving diazoxide

BACKGROUND

Frequent and severe gastrointestinal disturbances have been reported with the use of diazoxide in adults and older children. However, no studies have investigated the incidence of necrotising enterocolitis (NEC) in diazoxide-exposed newborns.

OBJECTIVE

To evaluate a possible association between diazoxide treatment for neonatal hypoglycaemia and the occurrence of NEC.

DESIGN

Multicentre retrospective cohort study.

SETTING

Three tertiary neonatal intensive care units in Toronto, Canada.

PATIENTS

All patients treated with diazoxide for persistent hypoglycaemia between July 2012 and June 2017 were included. Overall incidence of NEC during those years on the participating units was obtained for comparison from the Canadian Neonatal Network database.

MAIN OUTCOME

Incidence of NEC after diazoxide exposure.

RESULTS

Fifty-five neonates were exposed to diazoxide during the study period. Eighteen patients (33%) showed signs of feeding intolerance, and 7 developed NEC (13%). A diagnosis of NEC was more prevalent in the diazoxide-exposed, as compared with non-exposed infants of similar gestational age (OR 5.07, 95% CI 2.27 to 11.27; p<0.001), and greatest among infants born at 33-36 weeks' gestation (OR 13.76, 95% CI 3.77 to 50.23; p<0.001). All but one of the neonates diagnosed with NEC developed the disease within 7 days from initiation of diazoxide treatment.

CONCLUSION

The present data suggest a possible association between diazoxide exposure and the development of NEC in neonates. Further evaluation of the diazoxide-associated risk of NEC in neonates treated for persistent hypoglycaemia is warranted.

Ampicillin Pharmacokinetics During First Week of Life in Preterm and Term Neonates

BACKGROUND AND AIMS

Ampicillin is 1 of the most commonly used antibiotics for treatment of early onset sepsis, but its pharmacokinetics (PK) is poorly characterized. We aimed to define the dose of ampicillin for late preterm and term neonates by evaluating its PK in serum, cerebrospinal (CSF), and epithelial lining fluid.

METHODS

A prospective study included neonates receiving ampicillin for suspected or proven early onset sepsis and pneumonia. PK samples were collected at steady state, at predose and 5 minutes, 1 hour, 3 hours, 8 hours, and 12 hours after ampicillin 3-minute infusion. Ampicillin concentrations were measured by ultra-high-performance liquid chromatography. Noncompartmental anaysis (NCA) and population pharmacokinetic (pop-PK) modeling were performed and probability of therapeutic target attainment was simulated.

RESULTS

In 14 neonates (GA of 32-42 wks; mean BW 2873 g), PK parameters (mean ± SD) in NCA were the following: half-life 7.21 ± 7.97 hours; volume of distribution (Vd) 1.07 ± 0.51 L; clearance (CL) 0.20 ± 0.13 L/h; 24-hour area under the concentration-time curve 348.92 ± 114.86 mg*h/L. In pop-PK analysis, a 2-compartmental model described the data most adequately with the final parameter estimates of CL 15.15 (CV 40.47%) L/h/70kg; central Vd 24.87 (CV 37.91%) L/70kg; intercompartmental CL 0.39 (CV 868.56) L/h and peripheral Vd 1.039 (CV 69.32%) L. Peutic target attainment simulations demonstrated that a dosage of 50 mg/kg q 12 hours attained 100% fT > MIC 0.25 mg/L, group B streptococcal breakpoint.

CONCLUSIONS

We recommend ampicillin dosage 50 mg/kg q 12 hours for neonates with gestational age ≥32 weeks during the first week of life.